Hostility In Adolescence II:
The Hostile Adolescent In Psychotherapy
Adolescents entering therapy present a variety of development-based problems to the therapist (Freud, 1958;
Bios, 1962). These demand that adjustments be
made to the standard techniques used in work with adults (Meeks & Bernet, 2001).
Specific adolescent problems may compound the common difficulties inherent in psychotherapeutic
work with adolescents. Experience suggests that the hostile adolescent,
defined here as one in whom hostility has become a characteristic personality feature, may be one of the
most challenging of troubled youths that we face in our clinical work.
The preceding chapter explored the salient developmental & clinical aspects of hostility as they unfold & in their manifestations during adolescence. This chapter
focuses specifically on the theoretical & technical aspects of psychotherapeutic work with such youths.
Successful intervention with the hostile adolescent in need of psychotherapy usually requires working thru 3 successive phases of therapy.
The first is engaging the frequently highly resistant youth in the process of therapy & developing the needed therapeutic alliance.
The 2nd is identifying the myriad ways in which
hostility is dysfunctional & is disrupting the youth's current life &
jeopardizing his or her future, while simultaneously exploring the roots of that hostility.
The 3rd is offering realistic, adaptive alternatives to its expression.
Hostile adolescents are certainly among the most resistant to entering therapy. The more intense & generalized their hostility & the more subject
they are to projection & paranoid feelings, the truer will this be. In its more severe forms, the hostility is characterological & egosyntonic & these youths see no need for help.
Because they're typically more rejecting of dependency on their parents then the
average adolescent, they're wary of becoming dependent on another authority figure, especially one chosen by their parents.
They're frequently angry at the world & a probing therapist is certain to be viewed with mistrust.
When such youngsters find their way to a therapist's office, it's often for reasons unrelated to their hostility. Academic failure & trouble with the law are common reasons for referral, the hostility becoming apparent in the process of evaluation.
The source of the referral is often extrafamilial. The symptom alone seldom constitutes
reason enough for the parents to seek psychotherapy for their child, because they may not see it as a problem. It's only when
the youth's behavior at home becomes intolerable that they may seek help.
If they've been abusive, they characteristically overlook or rationalize signs of disturbance in their child. Prognosis in these situations
is guarded, in part because the therapist is unlikely to have the cooperation of both parents.
Sabotage of treatment is common, especially if changes in the youth begin to threaten either of the parents.
In less severe cases, the hostility
appears as an occasional reaction, the described character resistance will not be present & the patient may even be relieved to discover a credible source of support & a potential advocate.
Evaluation
Assuming a measure
of cooperation that allows for an evaluation to be conducted, 3 questions
specific to this population must be added to the traditional assessment of an adolescent:
1. What's the level / nature of the hostility present in the adolescent?
2. Is the adolescent's home currently a hostile environment?
3. How does the adolescent patient handle anger?
In addition, the presence of comorbidity or evidence of associated symptoms such as substance abuse, depression, delinquency, or violence must be determined. Suicide risk must be assessed. As such data are factored in, the
initiatives to be taken, both immediately & over time, will become self-evident.
i.e., an adolescent seen in the emergency room who is displaying murderous hostility will require admission & a comprehensive inpatient evaluation. A self-referred
youth may describe personal anguish, suicidal thoughts, or an intolerable home situation to which he or she refuses to return.
Referral for outpatient treatment or to social services for possible placement may
be indicated. Another teen may turn out to be a gang member who admits to serious acts of delinquency & referral to the
family court will be the appropriate first step. Almost all of these youngsters have major problems in managing anger that must be addressed, the appropriate setting depending on the rest of the clinical picture.
Treatment: Theoretical Considerations
Assuming that
psychotherapy has been recommended as part of the treatment plan, the specific psychotherapeutic initiatives will depend on
the current developmental stage of the hostility &
on the nature of associated psychopathology. At times, the hostility is an understandable reaction of a generally healthy adolescent to intolerable provocation from a family member.
In such cases, the hostility
is likely to be aimed specifically at the offending relative. Exploration of the family dynamics that lead to such interactions
& end by eliciting a hostile
response in the adolescent is indicated. This
can then lead to a discussion of possible alternative responses that may be useful to the adolescent, even if the underlying
family pathology remains unaltered.
When the hostility has become
a character trait, it generally reflects a
hostile state of mind or attitude that finds regular expression in interactions with others. One speaks of hostile behavior, seen generally as inappropriate & damaging to interpersonal relationships.
Internalization of hostile feelings has occurred, displacement & projection are common & the adolescent may be viewed as (& labeled) a
hostile person. The hostility is now an integral part of the identity of the youth & the associated behavior follows a recognizable pattern.
When such a youth appears for therapy, the initial task of establishing a therapeutic alliance (a common problem w/adolescent patients) is made significantly more difficult by the existence of a hostile attitude & the adolescent's resentment over succumbing to external (usually parental) pressure.
It should be noted that the hostility may also serve defenses purposes & such defenses have to be respected (Vaillant, 1992). Where possible, consensual validation (Sullivan,
1953) of the patient's feelings as having some legitimacy & a consistently noncritical, empathie approach may permit the adolescent to become
less defensive & however tentatively, more trusting.
An assurance
that confidentiality will be respected is an essential element for establishing the therapeutic alliance with such youths, given the distrust that
the family pathology has fomented.
As therapy progresses, one should expect that transference elements will make their appearance, associated with the current content of the therapy & perhaps in reaction to particular interventions by the therapist. As this occurs, exploration of unconscious elements
& historical antecedents becomes possible & interpretation becomes the principal technical maneuver, clarification
& confrontation being used as necessary.
Getting Started
Clues as to how well the therapist-patient dyad will work and the issues likely to top the agenda from the outset may well emerge from the evaluation, assuming
that this is done by the eventual therapist. The right fit isn't always easy to assure, as generations of therapists have discovered.
The adolescent may provide an early opportunity for the therapist to be useful in some practical way; Anna Freud saw the role of the therapist as occasionally being that of a teacher. The patient may be in the midst of a crisis that calls for a quick response from
the therapist.
Somewhat later, the therapist may be called on to advocate with the parents for extended privileges for the youth. When that demand seems appropriate,
such intervention on the part of the therapist is an opportunity for useful work with the family. One must guard against being co-opted by the adolescent, or manipulated & ultimately rendered impotent.
This risk can be mitigated by arranging for some family sessions at which all perspectives
can be aired & (it's hoped) a resolution reached. This tends to discourage any manipulation but may have the additional benefit of diminishing the not-uncommon feeling on the part of the adolescent of always being blamed.
Occasionally, a youth agrees to cooperate with no real intention of participating honestly in the process. These tend to be youngsters who have something to hide (e.g., substance abuse or delinquent activity), their reticence often a sign that an antisocial personality disorder
may already be nascent.
The principal hope for success with such youths lies in being able to identify the presence of concealed fear or internalized conflict about these activities & in convincing the youth that real help with what may be life-threatening problems
is actually available.
Failing that, a therapeutic alliance may be impossible to establish
& the therapy may have to be abandoned. Sadly, these are often youngsters who would probably have been accessible at an earlier stage of their development
had their caretakers recognized the need, been sufficiently concerned & sought help when symptoms first appeared.
General Principles
We've noted that the therapeutic challenge varies in direct proportion to the intensity & form of the hostility, the nature of coexisting symptomatology, the presence or absence of internalized conflict & the level of cooperation of the parents. Before proceeding to a consideration of each of these elements,
it may be useful to review some general principles of adolescent psychotherapy that are pertinent to the present theme.
Perhaps the most basic principle of working with adolescents certainly the first
lesson I learned as I entered the field - is the need for flexibility.
Clearly unorthodox when this notion was first presented to me some 45 years ago, it's
today commonplace & needs no elaboration. A useful approach to all adolescents, it's a sine qua non for this particular population. In
practical terms, it calls for more than the usual activity & a degree of personal involvement on the part of the therapist, as well as a readiness to make use of all existing treatment modalities at any point in the therapy, jointly or in tandem, integrating these approaches to the extent possible (Lewis, 1997; Kalogerakis, 2003).
2nd, until proven otherwise, an adolescent's problems should be considered a family affair. When this becomes apparent, it calls for a careful evaluation of parental pathology, especially
as this has special relevance for the symptom of hostility in the adolescent.
Adequate treatment
of any adolescent may at some point require engaging the family. Further, as I have elaborated elsewhere (Kalogerakis, 1997), it's essential to distinguish from the outset between the
3 spheres of psychological activity:
- reality
- the interpersonal
& the intrapsychic
- to deal with them
sequentially to the extent possible
if therapy is to proceed effectively
This, too, has particular validity for this population, because all 3 elements play a critical role in the unfolding of a hostile personality organization.
Finally, whether one decides to proceed with a psychoanalysis-based treatment or not,
given the relevance of early childhood roots in the presenting problem & the ubiquity of unconscious elements in the psychopathology
that has developed, a psychoanalytic perspective isn't only useful but essential.
Addressing Hostility
Turning now to the specifics of treatment of the hostile adolescent, let us consider the nature & form of the symptom & its importance. Prior to generalization of the hostility, the adolescent is still
hopeful that a new adult will be kinder & more compassionate than what he or she has previously experienced & is consequently needy, open & - though cautious - nonetheless available.
Ralph, 16 years old, had been in therapy in earlier childhood for a learning disability & a troubled relationship with his verbally abusive father. He was referred this time because of generally hostile behavior at school:
- claiming that he hated all of his classmates & posting signs advocating the rape of minority women.
Since the boy was generally quite submissive, this act was totally out of character
& occurred under the influence of another youth. He was visibly frightened on arrival for his first session, yet entered therapy willingly. He welcomed the support he received & had no problem establishing a therapeutic alliance.
In
this case, the therapist's interest & empathy were timely, prompting the patient to make his emotional life & unconscious accessible. Intervention consisted
largely of clarification, with a minimum of interpretation of the unconscious. The therapy was helped by the fact that the parents had divorced & the father had entered therapy & mellowed in his dealings w/his son.
Transference issues were nonetheless in evidence. At this level of pathology, transference is
likely to consist of experiencing the therapist as a nurturing figure, an idealized parent, or a powerful (though
potentially dangerous) authority. The prognosis
for these youths is favorable, providing that current parental abuse, when present, can be mitigated, usually via direct intervention with the parents.
Once the hostile response has
been internalized & become part of the defensive repertoire of the child or adolescent (in reaction to perceived mortal threats), it's more difficult to contain. Generalization of the response to others beyond the original offenders
invariably results in distorted perceptions & misreading of intent.
Trust has been severely compromised, there's evidence of numerous
internal conflicts & anxiety is likely to become chronic. Object relations suffer & the youth may become increasingly isolated & depressed. The entire sequence may be seen as defensive; it's unfortunately maladaptive.
Because we're dealing with conditioned responses - a habit pattern & because
that pattern is based on deeply held beliefs & a continuing sense of vulnerability, insight - producing analytic work
is indicated, often into the adult years.
Although the
present focus is on adolescents, it's hoped that the following brief descriptions of 2 adult patients in whom hostility came to play an important role after their adolescent years will help to emphasize these points.
Mr. Smith is a highly successful businessman who, as a child & adolescent, had been
severely abused by his father, both verbally & physically. The damage inflicted was chiefly on his personality development;
the boy became fearful & insecure, feeling inadequate & unlikable.
Superior intelligence & academic excellence did little to alter this picture, which
persisted thru late adolescence & well into his adult years. As he began to draw on his native resources & to assert
himself in his work, a gradual transformation occurred:
- the meek young man
became an aggressive, hostile, highly competitive individual with a sharp wit, who could cut
the opposition to ribbons.
At some point, however, he became increasingly depressed & even suicidal, as his personal life left him progressively
unfulfilled. Analytic work ultimately clarified the central role of his hostile disposition in the genesis of the chronic state of depression & led to salutary effects
on both work & general adjustment.
Psychodynamically, key features were unconscious identification w/the father &
a wish for homosexual submission, expressed consciously as murderous hatred, eventuating in preconscious self-loathing & self-hate. The etiological connection between hostility & some forms of severe depression was strikingly confirmed.
Ms. Jones, a successful professional woman, entered therapy in her mid-20s, concerned about repeated interpersonal & romantic failures. Attachment issues, general mistrust & a judgmental style were prominent symptoms. Mistrust of the outside world had
been inculcated early by a father who insisted that home was the only safe place.
At the same
time, he was given to rages & harsh criticism of his wife & 2 daughters. For the girls, home was at best inconsistently
nurturing & scarcely ever a safe haven. Parental inconsistency was evident in the parents' prohibiting any expression
of anger toward them by their daughters, while at the same time not intervening when sibling battles erupted.
Instead, the girls were left to fight it out, unimpeded even as a hostile sibling relationship began to develop. This continued into adolescence & adulthood. It was quite
apparent that the daughters were caught in an impossible bind, afraid of the outside world, unprotected by either parent &
too young to protect themselves. Ensuing anxiety led to anger & ultimately hostility & alienation.
What these 2 patients had in common were hostile, paranoid & impulsive fathers & weak mothers unable to step in as protectors. In such circumstances, the paternal rages meet the criterion of the mortal threat that constitutes the essential condition for the inculcation of a hostile disposition in the child.
The absence of any apparent solution, the sense of absolute helplessness, the feeling of betrayal by their putative protectors, all lead to anger, which, proving useless, is transformed at a fantasy level into a wish to annihilate the offender (i.e., hostility). Once this response is learned & repeatedly reinforced, it becomes
part of the modus operandi of the individual.
These dynamics appear to coexist, at least in some patients, with identification
with the aggressor (Freud,
1937), which can, in its own right, lead to a
repetition of the hostile
personality pattern in the next generation.
The hostile careers of both patients
were launched well before their adolescence. What's less clear is what the status of the hostile response & associated personality development was at adolescence &
what interventions might have served to prevent their progression & ultimate establishment as features of the adult personality.
These patients weren't seen in therapy as adolescents & it's therefore impossible to say how much of the above dynamics might have been elicited at that stage
of development. In part, this would of course depend on how analysis-based such therapy would be, as well as the age of the adolescent. This remains an important area for future research.
What we know from our work with adolescents is that, as psychotherapy begins to uncover the
roots of the hostility & the symptom is gradually
relinquished, related symptoms also begin to subside. Anxiety associated w/the fear of retaliation abates. Self-esteem, which had suffered as the adolescent came to see himself or herself as bad, also improves.
With such youths, persistent empathie efforts are needed to reverse the mistrust & convince the patient that all adults aren't like the pathogenic caregivers he
or she has known. As Furst (1998) put it,
"The
most favorable outcome in the treatment of aggressive individuals occurs when, in addition to interpretation & reconstruction, the analytic experience
provides the patient w/a new parent, who doesn't threaten or prohibit" (p. 176).
Returning to the personality context in which hostility may be found, it's clear that the most malignant form of hostility likely to be seen by a clinician is that which is found in the severe personality disorders, notably the borderline,
the narcissistic & the antisocial.
These disorders are infrequently encountered in their advanced state during early
adolescence, although recent research has shown that the borderline syndrome can be seen in its adult form from 14 years of
age on (Ludolph et al.,
1990; Westen et al., 1990; Westen & Chang, 2000).
As of this writing,
DSM-IV (APA, 1994) continues to hold to the position that personality disorders aren't
diagnosable before 18 years of age. However, Westen & Chang (2000),
in their ongoing research, have identified 2 personality styles & 5 personality disorders in adolescents that parallel
those listed in DSM-IV.
Currently, these authors are engaged in a study separating the early, middle &
late adolescents that they hope will provide the clearest picture yet of how personality & personality pathology develop thru the adolescent
years.
Hostility figures in the symptom picture of most of these syndromes, most frequently directed
at the parents, though it can also be generalized to other adults or even peers.
The following
two cases illustrate this.
Rosalie was a 16-year-old adopted child enrolled in a drug rehabilitation program when
she was referred for therapy because she couldn't fit in with the group at the center. She was considered weird by the other teenagers, flew into unpredictable
rages, lied about everything, was prone to fantastic fabrications of alleged experiences & events, was very promiscuous
& thought about suicide, making several gestures.
She felt rejected everywhere. In addition to
widespread hostility toward
almost anyone with whom she came into contact (but, it's interesting to note, not the staff at the center or her therapist), she was bitterly hostile to her parents, becoming physically violent toward her father on
numerous occasions. In group therapy, she enjoyed playing the role of the "crazy one."
Jimmy, 16 (also referred from a drug rehabilitation center), was unable or unwilling to participate in the treatment program. His attitude was one of hostility to virtually all of his peers. He saw himself as different &
was quite grandiose about his abilities & potential to be a rock star, composing typically violent lyrics for a ragtag
high school band with a heavy metal cast.
He once came into his therapy session wearing a boot the toe of which he had pierced with nails (pointing outward), in case anybody messed with him. He claimed to hate his parents, both professionals; this behavior was in sharp contrast to that of his 4 siblings, who were apparently
quite well adjusted.
His parents wondered whether he was depressed, citing a strong family history of
bipolar illness, including one suicide. The father himself was currently under treatment for depression. While in therapy, the boy was expelled from school for casually remarking to classmates that he was going to kill a teacher who had offended
him.
Like Rosalie, in therapy he was a superficially cooperative patient who seemed to be benefiting from therapy, until he was confronted about some of his more outrageous behaviors. seeing the end of secondary gain from a therapist he believed he had co-opted, he abruptly left treatment.
Both of these youths were consumed by hostility
& from every indication, had a rather grim prognosis. Would they continue on their pathological course & if so, would
Rosalie end up with borderline personality disorder & Jimmy with antisocial personality disorder?
In point of fact, though it remains unclear what if any impact was made by their
uncompleted therapy, both of these youngsters on followup seemed to have made satisfactory adjustments, with significant abatement of the hostility. The outcome lends support to Westen & Chang's (2000) suggestion that,
in adolescents, it's better to speak of personality pathology, w/its somewhat uncertain future, than of personality disorders, which have a much more chronic course.
However, the latter are seen, as in the example of another youth, Tony, with a history
of serious delinquency. He was remanded from the family court to a large municipal hospital for evaluation & was found
to be violent, homophobic & paranoid. He was imbued with murderous hostility.
Returned to court with a strong recommendation for training school in view of the
danger he presented, he was inexplicably released to the community. Within 6 months, he was returned to court, charged w/
murder.
Among psychoanalysts
who have studied the severe personality disorders in late adolescents & adults, Kernberg (1992) has concerned himself with hatred (or hostility) as a cardinal feature. In his formulation, hatred in these patients can be understood as an affect that combines the wish to destroy the object with a continuing need for that object.
He sees this paradox as being "at the center of the psychoanalytic investigation
of hatred" (pp. 215-216). These dynamics can be seen in less severe pathology, as in the case of Ms. Jones
discussed previously. They may also be identified in the severely disturbed adolescent, but it remains controversial whether they can be satisfactorily worked thru during the teenage years.
Collateral interventions
Coexisting psychopathology can be varied & calls for the usual appropriate ancillary
treatment. i.e., depression may require the use of antidepressants, which, for adolescents, would preferably be the selective serotonin reuptake inhibitors (SSRIs), which have proved to be more effective than the tricyclics, or interpersonal psychotherapy (Mufson
& Dorta, 2000), or cognitive-behavioral therapy, which some clinicians have used with success in the age group.
The ADHD child, who-given the academic or social failure (or both) commonly associated with this syndrome-experiences frustration &
anger & is always at risk of developing a hostile disposition, may require psychostimulants on an ongoing basis. Many personality disorders can benefit from medication that addresses
the specific symptomatology.
Finally, the paranoid schizophrenic, whose hostility is frequently based on psychotic terror, will need antipsychotic medication.
Integrating intervention with the family while the adolescent is undergoing individual therapy has already been mentioned as advisable at different points & can consist of a session or 2 with or without
the adolescent or, exceptionally, formal family therapy.
The latter would most likely be indicated when it's established that the current
situation in the home is a critical element of the psychopathological picture;
are common indications for intervention with the family,
almost always by the adolescent's therapist. When the parents require extensive help, referral to another therapist is the preferred course.
The Parent-Child Relationship
Apart from these
direct efforts with the family, a helpful initiative in working with the youth is to begin replacing the demonized view of the parents with a more humanized
view, one that makes their abusive behavior more understandable in the light of their own problems or apparent pathology.
The notion that the parents might not have been able to do otherwise & in particular,
that their behavior didn't result from some personal failing of the patient may come as a revelation to the youth.
This may begin to cut into the adolescent' s hostility toward them. In effect, several important goals are achieved:
1. A more realistic view of the parents as more humane & less omnipotent supplants the previous subjective, distorted perception.
2. The door is opened to a more meaningful dialogue & to establishing a more workable
connection with them.
3. The adolescent learns to replace destructive hostility with adaptive anger.
4. The adolescent discovers via the therapeutic experience that some adults are capable of being rational, supportive & empathic.
The hoped-for effect is to demonstrate to the patient the feasibility of a positive, constructive approach to life, supplanting the hopelessness commonly associated with ingrained hostility.
When the information is available, elucidating the pathogenic aspects of the parents'
own childhood, showing how they too were victims, helps to break the cycle of hatred that's responsible for the transmission of destructive affect from generation to generation.
Anger Vs. Hostility
Clarification of the relationship between anger & hostility
is a critical component of the therapy with such youths, as detailed in the preceding chapter.
Here it's sufficient to say that helping the adolescent to recognize the difference & to replace
destructive hostility with appropriate anger that can be managed constructively is very possibly the single most important contribution that the therapist can make to the youth struggling with hostile feelings & impulses.
In this regard, note should be taken of the multitude of anger management programs that target adults with substance abuse & mental health problems who have trouble controlling anger (Reilly & Shopshire,
2002).
Similar programs for adolescents have sprung up in schools & other settings &
are supported by both U.S. government & international agencies. Not surprisingly, these are group approaches that are
more educational than therapeutic, though they use cognitive behavioral principles & generally don't include parents.
They don't pretend to address complex individual problems with roots in the family
& consider hostility an attitude rather than an emotion. The jury is still out on the value of these programs which, as discussion groups designed to be cost-effective & to reach as many angry teenagers as possible, can't deal with the plethora of personal, underlying issues that afflict
individual adolescents.
Outcome studies suggest that an initial beneficial effect gradually attenuates & largely
disappears within two years' time.
Pyschodynamic
& Psychoanalytic Concerns
The psychodynamic issues likely to be encountered have been touched on throughout this chapter
& cover a wide range. To review, there's a fundamental self-esteem problem that originates in the feeling of being unloved, a consequence of the rejecting or abusive parent-child relationship.
Ultimate hatred of the parents leads to guilt & a profound sense of being bad. Because the parents are still needed, a destabilizing ambivalence reigns.
A sense of impotence
results from reinforcement of the normative adolescent dependency & accompanying helplessness. Associated passivity may further damage self-esteem & increase the sense of impotence.
Depression is the inevitable consequence. Once the hostility is expressed, the fear of retaliation can make anxiety a prominent symptom. Interpersonally, the dynamics of power & dominance complicate the picture.
These are the usual neurotic dynamics. When severe character pathology develops, there's significant damage to the ego, with low frustration tolerance, identity diffusion & impulsivity as prominent features.
The evolution of these dynamics may extend into the adult years & cause significant
maladjustment, as was especially evident in Mr. Smith (discussed previously).
How these conflicts may be aggravated by coexisting pathology is evident in the case of Ralph,
referred to earlier, whose learning disability contributed a biological component & a sense of being damaged to the feelings of inadequacy instilled by his father's abusive treatment.
It's unclear to what extent the father's abuse may have played a role in the etiology of the learning disorder, but this is certainly a known risk factor.
Treatment of the feelings of inadequacy & associated depression in such cases is made significantly more difficult by a reality that may appear unalterable to the child &
can be quite challenging to the therapist.
Hostile feelings may distort one's perception & interpretation of reality &
thus one's cognitive functioning. For the neurotic patient, defensive blaming can reinforce an existing paranoid feeling about how one is perceived. This can lead rather directly to the fear of a mortal threat that is the proximal cause of the hostile response.
This is but a partial list of the many psychodynamic issues that may confront the
therapist & need to be worked thru. In regard to day-to-day matters, a cognitive approach that addresses perceptions & interpretations of others' behavior & interactions, that also deals with
accompanying ideation, can add substantially to the therapeutic effort.
Transference & Countertransference
Prior to internalization of the hostility, the adolescent patient
may merely interact with his or her "habitual mode of relating" (Tyson & Tyson, 1986) & the symptom may not manifest itself in a true hostile transference
to the therapist.
As previously indicated, the therapist is likely to be viewed as an idealized parent who the patient hopes will be his savior. Such expectations would of course have to be brought forth & interpreted. On the other hand, psychosocially damaged adolescents
are likely to test the therapist repeatedly, either by consciously designed maneuvers or unconsciously, thru acting out.
The development of trust will depend on how successfully the therapist is able to convey his or her sincerity in wishing to help & that he or she isn't merely the parent's agent.
With internalization & the initiation of psychoanalysis-oriented psychotherapy, transference
reactions are more likely & apt to be more intense. For the neurotic patient, transference may still be relatively mild, not negative & not in need of interpretation.
However, at the more severe end of the psychopathological spectrum, Kernberg (1975, 1984, 1992), in his work with borderline & antisocial personality disorders, has found
that the level of disturbance & the classical psychoanalytic approach foster the development of intense transferences.
The hostility to the analyst, notably in the narcissistic patient with antisocial features, is
seen as issuing from the analyst's unwavering dedication (which the
patient hates because he needs it so), envy of the analyst's creativity as manifested in his efforts to develop understanding & rage at the analyst's constant examination of the patient's "conscious or unconscious corruption of all relationships"
(Kernberg, 1992, p. 233).
Kernberg sees this activity as leading to a transformation of a psychopathic transference into
a paranoid transference, which, as analysis proceeds to more advanced stages, can be converted (via the establishment of guilt) into a depressive transference.
I've observed a similar transformation in the clinical status of juvenile delinquents
in nonanalytic treatment & have felt it to be essential to a resolution of the internal conflicts with which the youths were struggling.
Kernberg calls attention to the danger of such uncovering in patients with malignant
narcissism with antisocial personalities, who can at times react explosively. He also underscores the common countertransference
reactions with all of these patients:
- a sense of exhaustion
- of efforts going to
waste
- of a lack of gratitude by the patient-all of which can lead to either disconnecting emotionally from the patient or a masochistic submission in which the analyst absorbs the patient's aggression & may collude with him
With adolescents, I haven't found it generally desirable to foster the development
of transference or a transference neurosis (Slansky, 1972). As noted, transference
reactions nonetheless occur, both at the outset of therapy & during its course & these must be dealt with, normally by interpretation.
Like
adults, hostile adolescent patients will regularly evoke powerful countertransfence reactions in almost any therapist (Marshall, 1979), even when the pathology is considerably more benign than that described
by Kernberg in his adult patients.
In addition to those mentioned by Kernberg in working with adults with borderline
personality disorder, analyst reactions include fear (which in
the presence of a real threat isn't purely countertransferential), anger that may reach the level of rage, retaliatory
hostility that can be acted out & a sense of failure & impotence.
