Adolescent Psychiatry (v.2, #1)

This issue features articles based on presentations at the 2011 Congress of the International Society for Adolescent Psychiatry and Psychology, held in Berlin September 14-18. The theme of the congress was Adolescence: A Second Chance? Ably organized by an international scientific committee headed by Annette Streeck-Fischer and Franz Resch, the program spanned the entire field of adolescent psychiatry, and included presentations on developmental psychology, neurobiology, psychoanalysis, social and cultural aspects of adolescence, and new research. Nearly 600 attendees from around the globe participated. The program included symposia, state of the art lectures, and posters. This issue of Adolescent Psychiatry features articles from many of the leading presenters at the meeting, as well as selected abstracts that summarize many of the other presentations, and describe new research. The overall theme reflected the consensus among those who work with adolescents is that adolescence is indeed a second chance, but one that is often missed because of insufficient attention on the part of societies to the needs of adolescents. Many young people enter this often tumultuous period already compromised in their development because of adversity experienced earlier in their lives. Some of them experience further adversity during their teenage years, in part because of their pre-existing vulnerabilities. It was clear from the many leaders in adolescent psychiatry from around the world that youth everywhere are facing major challenges, whether they live in the richest nations or the poorest. Many of the presentations focused on the need to look beyond symptoms and nomenclature to underlying psychological dysfunctions-difficulties with relationships, with attachment, with mentalization, with affect regulation, and with self-image- in order to understand and effectively intervene with troubled adolescents. Others described collaborative efforts involving multiple centers and across countries to study such challenging conditions as borderline psychopathology. Borderline personality disorder and eating disorders were the two most common topics in the program, reflecting the concern over the high morbidity and mortality associated with these disorders. ISAPP (www.ISAAP.org) was established in 1984 as an international professional society to fill a void in the mental health arena. It is the only multi-disciplinary international organization devoted solely to the mental health needs of adolescents. Initially it represented a collaboration between American and European (mainly French) psychiatrists. Now it includes psychologists and other mental health professionals and counts members from Europe, Africa, and Asia as well as North and South America. Meetings are only held once every four years, however, many ISAPP members are involved in many other organizations (such as ASAP) and thus see each other at other meetings. In addition, the Internet has greatly facilitated communication. In this global age, it is increasingly important that we collaborate and learn from each other. This issue of Adolescent Psychiatry is dedicated to that end. While we in the United States struggle with limits imposed on treatment by third party payers, other countries struggle with a scarcity of mental health professionals and a lack of organized mental health services. Countries in Western Europe struggle to provide help to immigrant families who have poured in from poorer countries. Nearly all countries are facing record levels of youth unemployment, and some have seen violent protests by youth who complain that their future has been stolen. Inability of youth to become emancipated adults in the developed as well as the developing world have made future prospects for many of our adolescents bleak, and undoubtedly will have long term effects on mental health, families and societies. All countries seem to be facing rapid societal changes that have challenged the traditional role of the family. With all these confusing and discouraging developments, it is encouraging to know that there are people carrying out innovative treatment programs, doing research and teaching others how to work with adolescents. This issue begins with a succinct and accessible overview of the psychoanalytic perspective on adolescence by Werner Bohleber, a leading psychoanalyst in Germany. Dr. Bohleber recalls Freud's revolutionary discovery of infantile sexuality, which had the effect of demoting puberty, heretofore considered as giving birth to sexuality. He goes on to summarize the contributions of Anna Freud, ego psychology, feminist psychoanalysts, self-psychology, attachment theorists, and others and in the end, points to the need not to lose sight of the importance of the adaptation to the sexually mature body as well as the cognitive aspects of adolescent development. He points out that it is not possible to synthesize all of these elements into a coherent system, but rather that each offers a perspective that explains important aspects of adolescence. Following this article is the welcoming address given by then ISAPP President-Elect (now President) Annette Streeck Fisher of Germany, Adam and Eve-The Story of Two Adolescents. Dr. Streeck-Fischer points out that the Biblical myth of Adam and Eve can be viewed as a story of adolescent development.....

Since Sigmund Freud introduced his revolutionary ideas in the early 20th century, many other theorists have made significant contributions to psychoanalytic theory, sometimes extending, sometimes challenging, the views of each other. Major contributions have come from developmental psychologists, empirical researchers, feminist psychoanalysts, self-psychologists, and others, each of whom has sought better explanations for normal and pathological psychological functioning than were currently available. As a result, we have arrived at a point in psychoanalytic thinking at which there are multiple explanatory models for mental phenomena, each of which offers a different window into the psyche. Rather than see these as competing, incompatible models, among which one must choose, it is more useful to view them as each offering crucial insights into development and functioning. This paper discusses the evolution of psychoanalytic thinking in terms of its relevance to adolescent development and psychopathology, and points out the strengths and weaknesses of each of the major views for understanding adolescents.

Adam and Eve - The Story of Two Adolescents by Annette Streeck-Fischer (10-12).
In this introductory address to the the Congress of the Interntional Society for Adolescent Psychiatry and Psychology (ISAPP) in Berlin September 14-18, 2011, incoming ISAPP President Annette Streeck-Fischer interprets the Adam and Eve story of Genesis in the Bible as a myth depicting adolescent development. Elements of sexual maturation, risk-taking, and separation from parents, are present in the story. We are reminded of the many challenges today's adolescents face.

Attachment theory and research can contribute to the self psychological/intersubjective approach to clinical work with adolescents. Focusing on affective interactions, several adolescent cases demonstrate how knowledge of the AAI (Adult Attachment Interview) can help practitioners recognize disturbed and disturbing affective interactions that serve as the conduit for intergenerational transmission of emotional dysfunction.

Attachment research, which began with children but was subsequently extended to adolescents and adults, has informed psychoanalytic theory and deepened our understanding of the essential continuities and discontinuities of development. This paper briefly reviews attachment theory and considers the relevance of ambivalent-preoccupied attachment, one of two types of insecure attachment, for understanding psychic vulnerability during adolescents. How current social and economic conditions have exacerbated the effects of ambivalent-preoccupied attachment on the attainment of the developmental tasks of adolescence is also considered.

The aim of this paper is to think over the importance of words and their transformative power in the psychotherapeutic treatment of adolescent patients who have been abused and ill-treated within their families. In particular, we try to analyze the long and winding path leading from abuse to the restoring and the introjection of what we term “the law” in these patients. The law structures the inter-subjective space with meanings and is based on the recognition, the respect and the value of the otherness. It is an open, unsaturated, transformative work. The therapeutic setting, our law, is shaped to be the place of differences and agreements: it is a parental function, which separates and protects at the same time. In our adolescent patients who have experienced trauma, the identification process based on self-awareness cannot occur, and a pseudo-identity develops, based identification with the trauma. The psychotherapeutic setting is attacked as the place of recognition and evidence, involving the threatening fantasy of a catastrophic change. Working with these patients in treatment, the therapist's primary function is to be a living witness and the therapeutic setting is the frame within which the denied truth can be recognized and testified. “If somebody speaks there is light” is a metaphor for the therapy.

The developmental task to accept one's inborn mortality and thereby to propel one's procreative strivings cannot be mastered before adolescence when the transforming person is crossing the border between childhood and adulthood. The difficulties to integrate infanticidal/destructive strivings into life supporting needs in adolescence as a precondition for well caring parenthood often appear to be due to defenses against remembering traumatic experiences. These developmental concepts will be exemplified by vignettes from the psychoanalytic psychotherapy of an emerging young adult woman and mother of a most difficult baby.

In the field of developmental research, there is a pressing need to develop clinically sounded and empirically grounded tools for the assessment of personality development in adolescence. After a review of the relevant literature on adolescent personality disorders we present through empirical data and clinical material the IPOP-A, a semi-structured interview for adolescents ranging from 13 years old to 21 years old. The IPOP-A seems to be promising to gather information about processes that constitute the building blocks of adolescent personality organization.

Although some refugee and immigrant adolescents are at increased risk for psychological problems, most adjust well to their host countries. However, there is a lack of knowledge about those very recently arrived. This study assessed if pre-migratory exposure to trauma (i. e., violence and persecution), family separation, and status in the host country predict emotional and behavioural symptoms (self- and teacher report) in a community sample of 111 migrant adolescents attending integration classes in Montreal. Exposure to pre-migratory trauma predicted greater emotional symptoms on self-report. Family separation and status did not predict symptoms. Overall, these results suggest attention should be given during the initial post-migration period to adolescents who have experienced pre-migratory trauma because they may be at increased risk for internalizing problems

The aim of this study was to investigate the relationship between self-differentiating perceptions and the separation-individuation process in adolescent twins compared to non-twin siblings. A group of 32 twins aged 12-20 years, and a group of 31 non-twin adolescents aged 12-19 years were evaluated using a socio-demographic and clinical information form, the Sibling Inventory of Differential Experience (SIDE) and the Separation-Individuation Test of Adolescence (SITA). There were no significant differences between the twin and the non-twin adolescents with respect to mean scores of SIDE and SITA subscales. Although there were significant differences in the relation of differential peer characteristics to separation-individuation process in two groups, differential experiences of twins related to interactions with their co-twins, mothers' and fathers' affection and controlling behaviors were much more correlated with healthier separation-individuation in adolescence compared to non-twin adolescents. The above-mentioned aspects of selfdifferentiating perceptions of twins will be important in helping them during the process of separation-individuation

This study examined the results of nine years of follow-up of group therapy with adolescents at a clinic in Montevideo, Uruguay. “Groups of adolescent life” started in the year 2002 with regular weekly sessions lasting 60-75 minutes. Five to 14 youngsters of both sexes participated in each group; the ages were between 10-12 and 12-15 years old for some groups, and between 16 -18 and 19-21 years old for other groups. The Photolanguage® technique was used. It consisted in the choice of a photo to answer a question asked by the therapist at the beginning of the session; this created a new ludic situation that facilitated the expression of emotions. The main purpose of the therapeutic-groups was to promote good interpersonal relationships within each group as a way to improve further communications with peers and adults. The groups encouraged the communication of feelings, and collectively analyzed individual situations; they also sought to develop the capacity of the participants to enjoy the human encounter. The main requirement was regular attendance, and the therapists guaranteed freedom of expression and respect for all opinions in an environment of participation where the adolescents could share their experiences and emotions. The adolescents responded favorably to the group situations, better than to individual therapeutic approaches. The groups allowed them to be more open and communicative, and to express freely their most serious conflicts. The youngsters were able to discover their personal uniqueness and commonalities, and learned to express their opinions as well as to listen, to accept, and to respect those of others. This enhanced their self-esteem and improved their day to day functioning.

Aims: A fundamental concept in Racamier's thought, concerning psychotic patients and their families, consists of the efficacy of speaking actions (Racamier, 1998). The speaking action acquires sense and meaning for those clinical situations in which words cannot speak, nor communicate, and interpretations hurt, attack, represent violence, or are not heard. This report aims at presenting an example of such therapeutic strategy for a 16 year old adolescent with borderline features who, becoming progessively withdrawn, has always refused any kind of intervention or treatment. This youngster's developmental history is of a relational environment saturated with “enactments” substituting for thought, determining difficulties in building significant relationships or any empathic trust with the significant adults in his life. Method: The intervention carried out by the staff started with speaking actions, rather than words. The report focuses on managing a moment of crisis in which the youngster asks to be rushed and put in a community structure. Results: The clinician, instead of interpreting the request as an “enactment” provoked by feelings of guilt or escape, considered it a speaking action” (Racamier, 1972) requiring attention without prejudices. In a personality structured by borderline characteristics, this intervention seems to confirm the necessity to find syntonic responses to the needs of the self, initially mediated by containing and affective action. This way of facing the crisis made the encounter with the therapist and the psychosocial team possible, while they offered themselves as adult models, truly interested in him and his life. This enabled him to gradually reactivate his vital functions and try out the experience of “relationship”. Conclusions: The symbolic action of accepting the request and the fact the psychosocial team presented themselves as a thinking group to the youngster, represented, for Luca and the other members of his family, the narcissistic container allowing him access his own inner world. Luca was able to start an individual psychotherapy process, opening himself up to and facing the work to be done to heal the relationship with his parents.

DEVELOPMENT AND PSYCHOPATHOLOGY “Wake me Up when I Turn 18....”: The Developmental Psychology of Adolescence and Implications for Psychotherapy Inge Seiffge-Krenke Universitat Mainz, Mainz, Germany In recent years, striking changes in adolescent development have occurred which have significant implications for psychotherapeutic work with adolescents and their parents. Many social cognitive developments have become noticeable, for example, increases in emotional control and in visualizing of or fantasizing about social interactions. However, greater cognitive functioning (e.g., thinking about possibilities) does not necessarily lead to better functioning (e.g., using contraceptives). Further, many studies have shown that early-maturing adolescents, particularly females, are at risk for developing psychopathology. Developing a mature body concept, restructuring identity, and forming romantic relationships are important challenges for many adolescents. New forms of media have contributed to accelerated intimacy and changes in friendship relationships. However, there are still more similarities than differences between on- and off-line friends. In addition, parentadolescent relationships have changed, as seen in a marked erosion of parental control and increased pressure to conform to parental expectations. Keeping secrets is, among others, a way of achieving autonomy from parents, particular in families showing a noticeable violation of transgenerational borders. Altogether, psychotherapeutic work with adolescents today is, more than ever, characterized by “jumping on a running train” (Geleerd, 1958). In addition, parents need support and guidance in raising their adolescent offspring. The New Adolescent: Some Psychoanalytic Considerations Mounir Samy McGill University, Montreal, Canada Objectives: In the therapeutic work with today's adolescents it is easy to retreat from the intrapsychic world in favor of cultural causes and more pragmatic here and now interventions. Furthermore, the issues presented by the new adolescent have rendered outdated the theory behind the “transition stage” between childhood and adulthood. They grow too fast and we need to rethink their deep unmet emotional needs. The objective of this paper is to suggest a more fitting developmental understanding that can better account for today's clinical observations.....