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Until relatively recently, the study of adolescence was synonymous with the theory and practice of psychoanalysis. The major contributors to adolescent development came from eminent clinicians and theorists, such as Anna Freud (1936), Peter Blos (1962), Erik Erikson (1950). The adolescent crisis, psychosexual maturation, identity formation, and the second separation–individuation phase are all psychoanalytic concepts that have remained alive ever since they were ﬁrst introduced during the twentieth century. Since then, the ﬁelds of adolescent development and adolescent psychopathology have diﬀerentiated greatly, and a myriad of theories and models, many developed in antagonism to psychoanalysis, have evolved. Grand theories and clinical observations have far less currency at the start of the twenty-ﬁrst century than do systematic crossectional and longitudinal studies.
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The discovery of adolescence by psychoanalysts became the entry point of the study of development across the life cycle. If an essential new set of tasks develops in adolescence, such as the creation of identity, then there was reason also to explore similarly signiﬁcant transformations in adulthood. The important initial point was to overcome the singular psychoanalytic focus on early childhood, especially the oedipal years. In this vein, Erikson and others discovered stages of adulthood that reach well into old age. Thus adolescent development has to be viewed in the context of a shifting conception of psychoanalytic developmental psychology which views early childhood as only one important period of development.
But there is certainly no consensus on the issue of development in psychoanalytic circles: Even now, most psychoanalysts believe that the formative periods in life are the early attachment years, and the oedipal period between the ages of 5 and 7. If there was a shift, it was less to explore the later stages of life and more to understand the earliest, pre-oedipal stage of development. It is this fundamental notion of early childhood that has denied the life cycle theorists, with all their creativity, a very signiﬁcant role in psychoanalytic practice.
However, adolescence, as the intermediary space between childhood and adulthood, has become a signiﬁcant aspect of most psychoanalysts’ thinking about development and psychopathology. This phase of life represents a theoretical compromise, a recognition that new transformations occur beyond the oedipal years, without needing to give up the primacy of early childhood for personality development and symptom formation.
With the majority of innovations about adolescence and the life cycle coming from outside psychoanalysis, it would be easy to dismiss the analytic approach. But many modern adolescent clinicians and researchers recognize that psychoanalysis has changed greatly, and that, when applied carefully, it continues to be an important interpretive method in the social and behavioral sciences. But such modern versions of psychoanalytic theory and research must include the many innovations of adjacent ﬁelds (e.g., Smelser 1999), especially the cognitive sciences, psychiatric epidemiology, anthropology, and academic developmental psychology.
The approach taken in this research paper is to integrate psychoanalytic concepts in an integrative framework called clinical-developmental psychology. This approach represents a synthesis of psychoanalytic concepts, especially Eriksonian identity theory, object relations psychoanalysis as well as cognitive-developmental theory. Thus, the integrated theoretical, clinical, and research perspective does not represent psychoanalysis proper, nor does it represent traditional cognitive psychology in the tradition of Jean Piaget. It is, instead, a working out of the contradictions of two signiﬁcant paradigms of human development that have formed the building blocks of a new synthesis. This new approach forms a dynamic and transformational theory of adolescent development and the lifespan, within a research paradigm and a diﬀerentiated treatment approach.
In general, psychoanalysis has become far more open to these kinds of syntheses than ever before. Bowlby’s contribution (1969), for example, represents an integration of psychoanalytic and ethological thinking. The result is neither psychoanalysis nor ethology, but a theory of attachment that is one of the most signiﬁcant advances of psychoanalytic thought. Modern psychoanalysis has become far more open, because of the rapid developments in academic developmental psychology and other ﬁelds and an increasing openness to integrate these approaches.
The popular notion is that Freud’s theory was about unconscious motivation, sexuality, aggressive drives, and the three structures, id, ego, and superego. Freud is, furthermore, credited with having created a comprehensive theory of human emotions. These general conceptions about Freud’s contributions are not incorrect, but they are incomplete. Freud was equally dedicated to cognition and logic. He was convinced that psychiatric symptoms and psychological conﬂicts could be deciphered following a logical, hermeneutic strategy of interpretation. He also described in the ‘Introductory Lectures’ (Freud 1933), as well as in ‘Mourning and Melancholia,’ a theory of human relationship, one that was to become the dominant modern psychoanalytic perspective called ‘object relations theory.’
These two Freudian approaches, cognitive and relational, have expanded over the decades and were joined by a major third psychoanalytic perspective, the life cycle approach. Interestingly, the cognitive branch of psychoanalysis came to overshadowed by the far more elegant and researchable cognitive contributions of academic developmental psychology, especially the work of cognitive and social cognitive psychologists. The life cycle approach, building primarily on Erikson’s work (e.g., Erikson 1950) was acknowledged in psychoanalytic circles but never really shaped central psychoanalytic theory and practice. However, as mentioned above, it did help to extend the traditional focus on the early oedipal and pre-oedipal years at least into adolescence, as a second period of separation.
The life cycle approach in psychoanalysis changed into a research paradigm primarily through the work of George Vaillant (1977). Vaillant introduced a hierarchy of defenses in the tradition of Anna Freud, extended their development beyond adolescence into adulthood, and deﬁned ‘families of defenses,’ deﬁned not only in negative terms but also as adaptive styles. Vaillant showed, for example, how projection, with its pathological preoccupation with others, is related to a higher level adaptive defense which he calls ‘empathy.’ Vaillant applied this hierarchy of defenses to a fascinating set of longitudinal studies, especially the so-called Grant Study of Harvard men selected for their health. These men have now reached their eighties, and the research on them has demonstrated that a set of psychoanalytic constructs that were widely viewed as unresearchable, such as defense mechanisms, can be studied rigorously, have a developmental core, and are one way to trace the evolution of development in adulthood.
The psychoanalytic approach to adolescent development and the lifespan requires us to address C. G. Jung as well. His insights have been impressive and continue to garner a larger readership interested in development, meaning, and spirituality. Jung was really the ﬁrst psychoanalytic thinker to dedicate signiﬁcant eﬀort to understand the transformations a person goes through during life. He was also fascinated by the collective symbols and unconscious processes of development and transformation in human development. While Jung had some interest in adolescents, his central developmental contribution was about midlife, what he viewed as a typical shift from the external world to an inner and spiritual life. It is not diﬃcult to create a bridge between these ideas to a theory of adolescent development. Many of Jung’s ideas apply to adolescent themes of creating a sense of collective belonging to a generation, to a preoccupation with ‘making it in the world,’ and a preoccupation with being unique.
But it is the so called object relations strand of psychoanalysis of Fairbairn (1952) and Winnicott (1965) and others that has become the organizer of modern psychoanalysis, in the form of Kohut’s self-psychology, as relational psychoanalysis, and as a research paradigm in the form of attachment theory. These relational approaches have reshaped the psychological and psychoanalytic understanding of adolescence. In the earlier version, the adolescent crisis was viewed as stemming from the need to separate, to overcome childhood identiﬁcations, and to create autonomy. For that reason, Blos called this phase the second separation–individuation phase (the ﬁrst one being the one that Margaret Mahler described for the toddler). In the modern relational version of the adolescent, separation is far less important than are new relational capacities, and new forms of interconnections between the adolescent, the family, and society. The psychoanalytic adolescent of the twenty-ﬁrst century is far less of a rebel who pushes the parents away than a person yearning for support and closeness, and wishing to ﬁnd a new balance between family relationships and new intimate relationships. It is impossible to disaggregate what represents a new reality for families, what is a new adolescent ethos, and what is a reframing of psychoanalytic theory. All forces are at play, and while there is no single psychoanalytic scholar who is developing a new theory of adolescence, many clinicians and researchers are contributing to this relational shift.
Erikson’s contribution, while having had limited resonance in psychoanalysis, continues to exert considerable inﬂuence in developmental psychology, despite the fact that he did not use traditional empirical methods of sampling and proof. He showed that understanding adolescence means to go deeper, to understand the cognitive and emotional dimensions of meaning-making. At the time of writing, no one has yet been able to combine these kinds of keen observations and theoretical synthesis when studying adolescent life. Erikson’s conceptualization of adolescent identity formation, and the processes it includes (crisis, diﬀusion, foreclosure, moratorium), remain the standard by which subsequent contributions are measured, even if those contributions might be far more precise and valid empirically.
Since Erikson introduced his work, much has changed in the world of adolescents. Given the social dimension of the construct, one would expect cultural and historic changes (what Erikson (1968) called ‘the historic moment’) to inﬂuence the very nature of the adolescent experience. But also, new theories and research evidence have reshaped our understanding of how meaning-making and identity formation develop in the second decade of life. It is these cultural changes of adolescence, and the new developments inside and outside psychoanalysis, that gave impetus to a clinical developmental synthesis of adolescent theory, research, and practice.
2. Clinical-Developmental Assumptions Of Adolescence And The Life Cycle
2.1 Development Of Representations Of Self And Other
Clinical-developmental psychology of adolescence has a foundation in a relational and interactionist perspective. Such a psychoanalytic and cognitive perspective views interpersonal relationships and their internalizations as essential dimension of human development, symptomatology, and more recently, psychological treatment. Some of the pioneers of cognitive-developmental psychology (e.g., Piaget 1926) took the interactionist idea and applied it to an abstract, epistemic, logical subject of self in relation to an equally cognitive and abstract general ‘other.’
Evidence has accumulated since then, that signiﬁcant relationships with less abstract ‘others,’ such as parents, teachers, siblings, and friends are constructed actively and interpreted by the self, and that one result is an internal set of self and object representations. The concept that relationships and experiences with important others become represented internally is common, despite many conceptual diﬀerences, to a number of theories of psychology and psychoanalysis. These theories include classical psychoanalysis and branches of the modern psychoanalytic schools, such as self-psychology, object relations theory, and attachment theory. They also include the developmental theories built on the ideas of Vygotsky, Piaget, Mead, and Baldwin.
Although psychoanalysts and attachment theorists all share the view that the weaving of various signiﬁcant relationships creates the inner fabric of the self, the clinical-developmental psychologist examines the typical transformations of relationships over the course of the lifespan (Noam and Fischer 1996). There is now evidence from a number of cross-sectional and longitudinal studies for the clinical-developmental view that internal representations of the self and others change over time in childhood, adolescence and even adulthood (e.g., Broughton 1978, Noam et al. 1995). This view owes much to Piaget and Kohlberg, whose early work on the moral judgment of the child (Kohlberg 1969, Piaget 1932) revealed that children’s constructions of social rules and relationships change systematically as they grow. Piaget and Kohlberg’s ideas have been reﬁned; new cognitive-developmental perspectives on the child’s relationship to the social world in general, and to important others, now exist throughout the developmental literature.
While clinical-developmental psychology is built on an understanding of normative cognitive development, signiﬁcant theoretical and clinical extensions of the traditional cognitive models have occurred. The psychoanalytic frame plays a very important role in these theoretical extensions. For example, there is greater awareness that representations of signiﬁcant relationships can be quite resistant to change, despite their potential for transformation. Even an adult tends to represent the parents as relatively powerful ﬁgures, at times continuing to view them from the perspective of a child. But although the inner representational life is conservative in nature, most people are capable of changing their perspectives on signiﬁcant relation- ships, and are able to do what attachment theorist have called ‘updating the working model.’
Clinical-developmental psychology recognizes the ﬂuctuations between progress and regress in development, the resistance to changing one’s early representations, and the evolution and progression that often take place simultaneously. These ﬂuctuations are especially strong during the adolescent years, when close relationships with the family have to be brought into a new balance with peer inﬂuences and identity development.
2.2 Normative Development
In order to understand the developmental dimensions inherent in adolescent psychopathology, it is essential to understand what occurs typically in ‘normal development.’ How else can we know which challenges arise naturally during this phase, and which represent the beginnings of serious deviation and maladaptation? For example, anxieties in early childhood are common (e.g., fears of separation, monsters, darkness, etc.) and are not necessarily a cause for clinical concern. But severe separation anxiety in middle childhood and adolescence is not typical, and such anxiety often requires clinical attention. Another example is presented by Oﬀer and colleague who have argued against Erikson’s notion of serious adolescent crisis as a part of normal development. They present evidence that ‘normal’ adolescence is far less conﬂictual and risky than thought previously.
While theory development and clinical observation, the traditional psychoanlytic tools, can help us to understand what is developmentally normal and what is not, it is only through empirical studies with community samples that these distinctions can properly be made. Such studies can also help us to determine what the prevalence of anxiety, aggression, depression, suicidality, etc., is in the child and adolescent population. How do they vary by socioeconomic class, geographical location, ethnic group, and gender? And how do these problems change over time? Answers to some of these questions have already come from large-scale longitudinal epidemiological studies (for a review, see Costello and Angold 1995).
These ﬁndings give us the tools to apply, in a meaningful way, the concepts of delay and aberrant pathways that have proved to be so useful to studies of mental retardation, delinquency, and psychosis. We can, for example, trace a delinquent’s moral development, allowing us to see that it is delayed in comparison to that of his nondelinquent peers (e.g., Gibbs et al. 1984). Findings such as these give us a developmental focus; they allow us to see that it is not only behavior or brain functioning that distinguishes delinquents from nondelinquents, but also level of adolescent socio-moral maturity. More importantly, once we understand the moral delay, we can, among other interventions, begin to focus our interventions on supporting the process of maturation of the cognitive system that guides moral development.
Clinical-developmental psychology, however, is not just an application of the study of normal development to the realm of psychological dysfunction. It is also a reformulation of a number of traditionally held assumptions of normative theory. Key among these reformulations is the view that adolescent symptoms may be expressed diﬀerently depending on the individual’s level of development (e.g., Noam 1988). Typically, in early phases of development, impulsive, action-oriented symptoms are more frequent, while later in development, internalizing symptoms such as depression arise with greater frequency. Therefore, the idea that higher stages of development are necessarily more adaptive, as is suggested by many developmental theories, requires serious reconsideration. The clinicaldevelopmental psychologist does not view development as progressing simply from egocentric, oral, unsocialized, or impulsive stages to those deﬁned by the ability to take another person’s perspective and show tolerance, empathy, and ‘phallic’ strength. Developmental theories have assumed this view for too long.
But we now know that a similar developmental course that leads to increased self-knowledge and strengths in some people leads to alienation, self-deception, and self-destructive behavior in others (e.g., Noam et al. 1995). Reaching Piagetian formal operations, for example, can throw the adolescent into a dangerous identity crisis, providing the adolescent with so many potential ‘selves’ that no choice seems possible (e.g., Perry 1970). Chandler (1973) referred to this cognitive crisis of adolescence as the ‘epistemological loneliness of formal operations’ (p. 381).
2.3 Age Chronology
The clinical-developmental approach is far less focused on chronological age than are most research approaches to development and psychopathology. Unfortunately, it has become quite common to label a model or study as being an example of research in ‘developmental psychopathology’ if age is introduced as a signiﬁcant variable. But chronological age is a very crude indicator of the underlying processes of biological maturation, cognitive capacity, peer and family relationships, and one’s understanding of one’s self. Age does, of course, play a role in development in most of these domains, but there is frequently a signiﬁcant variation in maturity in each of these areas within a single age group.
There are, of course, also age trends in some forms of psychopathology. For example, suicide rates rise dramatically in adolescence, as do other disorders such as depression, and conduct problems. Schizophrenia is typically an illness that begins in late adolescence or young adulthood. Age, therefore, can serve as a simple way to organize an understanding of many underlying pathogenic processes. However, the simplicity of this approach is deceptive (see Rutter 1989).
In psychopathological development, as in normal development, we often ﬁnd that chronological age is by no means a guarantor that basic cognitive and social-cognitive processes have occurred. For example, despite textbook claims to the contrary, many adolescents and adults never achieve formal operational thought (i.e., tables in a typical psychology textbook list adolescence next to formal operations, as if all adolescents function at that cognitive stage). While many adolescents have achieved a formal operational level of thinking, others continue to function at the level of concrete operations, and indeed may remain at this level for the rest of their lives.
Consequently, if we use chronological age as the principle developmental marker, then the important variations that occur in every group of normallydeveloping individuals will receive insuﬃcient attention. For the clinical-developmental psychologist, this suggests that chronological age needs to be supplemented with a domain-speciﬁc understanding of a person’s capacities in diﬀerent areas of development.
But, although capacities are often measured in terms of chronological age, the more sophisticated measurements of development that we have as we enter the twenty-ﬁrst century call on us to subsume the idea of chronological age into our understanding of progressive adaptation and skill acquisition. In so doing, our research ﬁnds signiﬁcant links between development and psychopathology in adolescents, where chronological age plays only a minor role. Level of social cognitive functioning and the shape of the internal self and object representations, rather than age, are often associated with speciﬁc disorders.
2.4 Lifelong Development And Recovery
Signiﬁcant developmental changes can, and regularly do, occur long after childhood and adolescence. The lifelong process of development has been described eloquently by Erikson (1950), Vaillant (1977), Baltes (1997), and others. But despite a great deal of progress in understanding the achievement of salient life tasks, meaning making, and cognition, little progress has been made in applying this understanding to psychological treatment and recovery. Indeed, little is known even now about typical problems and psychological dysfunctions that arise with development throughout life.
Critical to clinical-development is the understanding that at each point in life, fundamental shifts in cognitive, emotional, social, and interpersonal development are possible, and that these shifts follow a certain logic and organization. For example, adults who identify strongly with work, authority, and control, can become disappointed when others do not live up to their expectations. These inclinations to disappointment, perfectionism, and excessive control might be long-standing, stemming from compulsive character traits that were formed in childhood. But they might also stem from the way people, as adults, deﬁne their basic categories of self, their world, and their relationships. Perhaps the categories most central to them are responsibility, predictability, and accountability. These categories and their salience can change over time into a greater acceptance of human frailty and of the limitations of control and predictability. As complex ways of understanding and experiencing change, past rigidities are also revisited. Each new chapter in a person’s life typically rewrites earlier chapters. Understanding the ways in which people can transform their representational world allows the developmental therapist and developmentally oriented psychoanalyst to help the patient revisit old relationships, overcome old vulnerabilities, work through past traumas, and help to prevent new ones from occurring. But the clinical-developmental perspective puts a great deal of emphasis on the self-righting and healing potential that is triggered under the right therapeutic conditions.
3. Extending The Psychoanalytic Paradigm: Diﬀerential Therapy With Adolescents
The next brief section will deal with using clinical developmental principles to diﬀerentiate adolescent functioning and brieﬂy introduce diﬀerential treatment implications. For a more detailed discussion see (Noam 1988), where four diﬀerent levels of adolescent functioning and intervention strategies are described. Because of space considerations only two adolescent positions will be diﬀerentiated here. This section will show that there is no single treatment approach for adolescents, even youth who share the exact same age, but that the approach will diﬀer fundamentally, not only by diagnosis, but also by developmental organization of self and relationship representation.
3.1 Reciprocal–Instrumental Self-Complexity
Establishing treatments for adolescents who function at the reciprocal–instrumental self-complexity level is diﬃcult. First, these adolescents are viewed by society as delayed developers, and often have many problems adjusting to the demands placed on them. They tend to be oppositional, even delinquent, and have a concrete and instrumental approach to relationships. Adding to these problems is the fact that play therapy is not appropriate at this age, because it seems infantilizing to them. Many intervention specialists take account of the verbal capacities of these adolescents in devising a treatment strategy. Because these adolescents are often quite verbal, therapists expect the youngsters to talk about their problems. But talking therapies generally do not work, nor do treatments that require a great deal of self-reﬂection and insight. The therapist who tries such an approach is usually greeted with contempt and hostility, and can expect communication to break down.
And yet, it is these adolescent girls and boys who are at risk of developing problems at school, dropping out, using drugs and alcohol, behaving aggressively, and running away from home. They need a great deal of support and mentoring, in the forms of individual therapy and group interventions, to learn how to negotiate life, and how to develop goals that do not ‘get them into trouble.’ If adults are conducting the intervention, it is important they orient the work toward joint goals, giving the adolescent a great deal of room to decide what should happen. It is very important that therapists do not get caught up with questions such as ‘what kind of therapy am I pursuing,’ but instead that they remain extremely ﬂexible, leaving the oﬃce when it is appropriate, to play, eat, or walk. It is not by chance that coaches and child-care workers are often successful with these adolescents; they are often perceived as nonthreatening and available when the adolescent needs them.
It is also essential to create contexts of peer learning and therapy for these adolescents. These environments can help the adolescents to learn how to overcome their diﬃculties in empathizing with others. A combination of developing group intimacy and confronting problem behavior by peers is powerful in helping the adolescent overcome an over-reliance on self-protection and move toward a more mature developmental understanding of the self and the world.
3.2 Mutual–Inclusive Self-Complexity
At this point, talking therapy has a real potential for making the adolescent feel understood and supported. Sharing one’s inner life with adults and peers, and framing it in psychological terms, becomes a powerful motivation toward intimacy and recovery. Group conformity is at its height, and so is the constant fear of losing the ‘relationship base,’ of abandonment by parents, teachers, and friends. It is this fear of losing those who deﬁne the self, and of not ﬁtting in, that is a core feature of this adolescent’s adolescence.
The ability of these youngsters to frame experiences in psychological terms, to describe feeling states and interactions with important others, encourages most therapists to explore patterns and motivations, autonomous self-observation and critical judgment about self and relationships. These explorations usually lead to surprisingly superﬁcial descriptions, which frustrate both therapist and client. Surprised by this ‘lack of self,’ the therapist may interpret this state as an early, and primitive, manifestation of a separation– individuation problem. The clients, consequently, feel incompetent, sensing that they are not living up to expectations. Feeling inadequate leads to feeling hopeless, and clients are thereby silenced. The silence, in turn, makes the therapist and client often feel quite uncomfortable, increasing the potential for low self-esteem and depression.
There is no therapeutic model that clearly ﬁts this stage of adolescence, which is surprising in light of the fact that so many adolescents who enter therapy function at this level. One reason might be that we did not know about this developmental gestalt before the emergence of social cognition. Existing therapy methods that use supportive strategies run the risk of under-challenging the patient. The relationship can easily become stale as the adolescent waits for some challenge or some guidance in framing the problems in new ways.
Insight-oriented therapy, on the other hand, requires an observation of systematic patterns of the self which is not available to adolescents at this developmental stage. Following a set of goals that is experienced as self-chosen, questioning existing conventions, and creating new ones, requires a diﬀerentiation between the part of the self steeped in prescribed pathways and conventions, and the part that is reﬂecting, doubting, and questioning. Therapists can be sure that they have an ally in the patient, who can contain cognitively, at least under supportive conditions, both sides of the self. For that reason, more traditional psychodynamic therapy can be applied, which becomes even more viable as the person grows into full adulthood.
The psychoanalytic perspective continues to provide important impulses for the study and treatment of adolescents and their families. Erikson provided signiﬁcant theoretical tools, and Bowlby introduced a research paradigm that has been amazingly productive. But further integrations of perspectives, especially pertaining to the cognitive dimensions of adolescent thought, have proven necessary. The clinical-developmental approach not only expands the theoretical tools for the study of adolescent development and adolescent risk: It also introduces a developmental typology of intervention and prevention strategies. Intervention advances with adolescents have been slow, despite the introduction of many strategies. It is possible that progress has been slow in part because the emphasis has been primarily on diﬀerentiating disorders, rather than on understanding these disorders in the context of adolescent development.
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