Expressions of trauma in the first sessions with the adolescent
by Gianluigi Monniello
My comments, which are psychoanalytically oriented, derive from the first sessions where the focus is on the transactions in the moment that the trauma is expressed itself and begins to occupy space in the mind of the traumatized adolescent in the presence of the therapist.
Briefly remembering Freud (1916-17) who taught us that: the foreign body (trauma) is not a pure external affliction, like an infection, but an internal foreign body; trauma has a deep tie with the memory (the remembering); and that which is traumatic always has to do with that which is desirable.
My clinical descriptions report the first meeting and references to stories in which trauma seems to consist in the failure of any possibility of links and mental representation. Then the main characteristic of these traumatic events seems to be their unrepresentability for the mental apparatus of these adolescents. The traumatic experience happend in early adolescence in the first two cases; in the third case the trauma showed up at the beginning of puberty. I knew about these facts. In all the three cases I noted the positive use of the countertransference to involve the patient immediately to move the therapy forward. The initial impressions described in the three cases are corroborated with data that emerged later in the therapy.
When she was 13 Antonella had a car crash with her boy-friend, which caused cranial trauma leading to a coma for two months with left hemiplegia. She was in a specialized hospital for a year. Then she returned home and returned school. She has numerous neurological and neuropsychological residua that need frequent and continous rehabilitation.
ura, anche in relazione alle situazioni che si vanno determwhere to put herself. Then she looked around, and without ever meeting my gaze, made a number of negative comments about the environment, especially the room we were in. She said that it was spacious, but she did not like the color of the walls because it was indistinct. I said that maybe she feels a little uneasy, and strange due to finding herself in a new room with a doctor she does not know, and not recognizing anything familiar.
Angela began: "I came because I feel bad, nervous and I want to get better." She scratched a leg, then an arm: "An insect has biten me, I'm allergic to bites... That was a horrible period... I had decided to leave school because my classmate and the teachers did not understand me. But when I found myself at home it was even worse; I was always alone, I never went out and so I began thinking, thinking... When you think to much you think sad thoughts, thoughts of dying." She spoke without stopping, in a loud voice, jumping from one subject to another with occasional brief eye contact. She said that then she began to stutter. "Mummy says that I do it on purpose, but it's not true. It happens when I feel guilty, when I've done something I shouldn't. Like when I told a friend that I tried to kill myself."
She stoped and then talked about Daniel, a boy of whom, she was fond, but who was very unreliable. Above all he did not believe her. I commented that it must be very painful not to be believed, especially by people whom she trusted, and it's a little like not being seen. She then talked me about a series of male friends who betrayed her, allowing me to imagine that most of this episodes were of sexual advances. "Also, when I tried to commit suicide, Daniel was very hard with me. That afternoon I had some friends over, a girl and two boys. Then one of the boys went home and the other one made advances to me. After we had been together he told me that it wasn't me that he liked but my girl friend. Even for me it wasn't something important but there was no need to say so... I was very upset. When he went in to the other room and tried with my girl friend my world fell apart, and I decided to take my life. I drank some beer and a lot of vodka. I took a lot of pills, I remember my girl friend calling me, but I wasn't able to answer... They told me that my lips were violet and I was so pale... I remember the hospital, the tube in my nose and thinking... why have they saved me ?
The worst thing was that I wanted my mother but they would not let her in because she would be too upset... There was my father whom I can't stand... a useless presence," she added, with great bitterness.
Now Angela seemed very tired, the tone of her voice softened. After a few seconds of silence she murmured: "They are always so worried about their own problems... But I need to speak, to be understood because I am agitated, nervous." When she left, she apologized saying that when she speaks she has the sensation of losing herself..., but today she feels she has followed a certain thread.
In the following sessions Angela talked clearly about the incestous relationship with her father. She muttered: "At 12 years old, your father climbs in to your bed, he comes to bed with you..."
The tale that followed these first few dream-like words were not followed by logical thinking, but were composed of fragments of thoughts as if the whole episode had not yet reached an inner coherence.
Angela's reference to the mother that she feels empty and undefined, immediatly showed that the problem existed before the oedipal stage and the incest with her father. It seems important that the therapist can face this delicate passage and remain in the background, because to try to impose his presence as a separate object would risk Angela being traumatized again. The first reference to her trauma seems to be the persecution espressed by Angela in the way she talks of the insect bites. She manifests her anxiety by presenting an injured and vulnerable body, and then refers to the traumatic experience when she talks about her attempted suicide.
The origin of her trauma consists in the failure of her primary object and the emptiness it left. This would explain the impossibility for Angela to abandon for any length of time the incestous situation because this would mean the risk of a breakdown due to the fear of the unknown and resurfacing abandonment feelings. I sensed that the entire session is characterized by not directly revealing a difficult secret, but rather by leaving its discovery to intuition. If, on the one hand this expresses the fear of being retraumatized, in the sense of not being believed, of not being able to trust the other, it refers to intrapsychic aspects typically linked to this type of trauma. We refer to the problem of the secret in incest and the subtle collusion that binds the abuser to the abused, and therefore to the fact that revealing the secret means participating in the guilt and facing one's own guilt. In other words, not speaking is a defensive action against the pain of elaboration.
The origin of the trauma is placed in the failure of the primary object and the void left by this object. This would also explain why it was impossible for Angela to abandon the incestuous situation for so long, because this would have meant running the risk of breakdown as a result of the fear of abandonment and the unknown. The incestuous situation seems to have represented the manifestation of a need to fill a structural void. The fusion with the penis of the father (a substitute for the breast of the mother) seems to have been an attempt to obtain the necessary narcissistic support and to escape from a sense of emptiness and depression. Angela, through her stories and her experience, seems to confirm that the true trauma was not so much the actual experience, but rather its deferred action (après-coup) and the awareness of its significance.
Stefania'a mother phoned for a consultation for her 13-year old daughter who wanted a sex change, and says that Stefania has made a wooden penis that she wears under a pair of men's pants. Stefania had a pretty face with her hair in a ponytail, wore a tracksuit. When I asked her to follow me she did so at once, and asked to which room we were going. Her voice is decidedly masculine.
She said: "What do you want to know? You know everything. I am a boy in a female body. I brought something I wrote knowing I was coming here, for you to analyse." She removed a wallet from her back pocket and gave me some papers. "This is my secret diary. I tell the story of my love for Giusy. I met Giusy on the phone and I gave her this name. I chose her phone number from a list of transsexual men published in a newspaper and I decided to call. After trying many times she finally answered. I shouted: "Please don't hang up. I'm alone and you sound so nice." She replied: "I've just got in. I've got a lot of work to do, darling. This is my work number and you must leave it free." She gives me an appointment. I thank my guardian angel that I'm not alone anymore because I have found a friend. Now I will save Giusy, I swear."
This is how Stefania introduced herself.
I felt I had been involved in some way. Perhaps she heard that I could not meet her immediately during the telephone call from the mother, although I had still given her an appointment for only a few days later. Stefania had waited anxiously for the encounter and prepared herself.
The session began with the description of another meeting.
"Tomorrow I go to the doctor. This is my real psychic identity: my name is Stefen and I am of average height; I am a "trans-boy" and this year I begin high school. My hobby is occultism. I lift weights. I like a girl 11 years older than me. She has short hair and is my opposite. I have long hair and a classic look."
Interrupting her reading, she says: "I really need someone to talk to. I began to understand everything when I was 5. Then, I always played with my cousin, who is now 18. We were inseparable. Now I read a lot of books about occultism and the Middle Ages, and I like books about friendship and the Secret Masters. I'm trying to understand why I am cursed in this way. I now call my periods the Devil's pump. My first period was a trauma. I screamed and wept. Things are better now: I made a wooden penis and paper-maché testicles, so I feel more protected. Then there is my soft rubber snake called Aleppe, who keeps me company. I hold him when I sleep, hugging my pillow. When I was a child I had a doll as big as me. I undressed it when I went to bed and held it close to me. Now I have lots of dreams about love. I imagine holding and hugging Giusy. They are pictures of kisses and hugs. There is a dream I remember and I would like to tell it to you."
I replied by calling her Stefania and suggested that perhaps it would be better if she used the formal Lei form of address with me. I wondered why I am trying to maintain a little distance. I saw her as a girl and I wanted to play an important role for her.
She continued to speak about herself as a boy and used the informal Tu with me. Stefania said: "There is an old man who asks me if I am a male or female. I answered: "Something in the middle." This person smiled, said "Great" and went away. He went into a lift and the lift descended." I wondered about the old man and asked her: "Did he look like anyone you know ?" She replied: "No, I couldn't say, but he wasn't angry that I didn't know how to answer. Certainly I have lots of things to tell you before you diagnose me, the final piece of paper I need for the operation."
I told her we had all the time in the world. She said: "Next time I'll bring you the story of Nico. It's a story I've written about the adventures of two knights who go to rescue a princess imprisoned in a tower."
I was struck by her idea and said: "I like fairy tales very much. It must be a wonderful story! There are two knights coming to the rescue at once!"
I considered that her imprisoned female side might be freed through a psychotherapeutic process now focused on a homosexual relationship. Namely a reciprocal early mother-child interactions of admiration, in relation to the traumatic events and carried out through a formal regression of thought, which would serve a reorganizing function and counter the primary trauma, the gender identity disorder. However, I realized that I have already been written into Stefania's script. Does all this mean that she expected from the object only the attention that her script solicited from me?
I felt that there was no difference between what happened in the first session and the analysis that followed. Stefania and I found ourselves facing our internal worlds and that of a stranger. Writes Odgen (1989): "It is always a risky business to stir up the bottom of the unconscious. And this type of anguish is rarely recognized by new therapists. It is interpreted as the fear that the patient will abandon the treatment, when in reality the therapist fears that the patient will remain."
Stefania considered the shock of puberty (Oppenheimer, 1983) the trauma that finished the illusions of her infancy. It was something that came from outside without any sense, unfair, scandalous. There was a disavowal of the body reality. "I can't pretend I'm a boy." The reality is that of the disavowal, and asking for a sex change allows the disavowal to function in reality.
It's difficult to do constructive linking of shared meanings in Stefania's rush of words, full of images. Is the infantile trauma not representable? I consider here the presence of a negative side of a traumatic event whose main characteristic is its unrepresentability, opposed to the positive side of the trauma which is a representational order.
My experience with these traumatized adolescents has prompted me to examine the mental functioning of the therapist in response to the mental functioning of the adolescent, which is often more dominated by perception and sensation than by thought and mental representation. I feel that the adolescent therapist is particularly exposed, owing to the economy with which he must use his technical armamentarium, i.e. the setting and interpretation, at moments of unease caused by the flow of representations that such patients elicit. The therapist's mental functioning may then take the hallucinatory route and lead to a dream or nightmare. Even if this does not occur, his "threatened" ego will find the solution in the transformation of thoughts or ideas into mental images following a regressive path. That is to say, word presentations are taken back to the original, infantile representation of things which correspond to them. Referring to the regression of the preconscious day's residues which takes places in dream-formation, Freud (1917) writes: "In this process thoughts are transformed into images, mainly of a visual sort; that is to say, word-presentations are taken back to the thing-presentations which correspond to them, as if, in general, the process were dominated by considerations of representability." Thus, when faced with the profound unease of possibly entering a crisis of mental representation himself, the therapist can, in the absence of dreamwork, consider the support of his mental image.
I have paid special attention to the economic and dynamic value of the "sensory power" of the analyst's mental image and its use in treatment, following C. and S. Botella. They write (1988): "Following the perceptive traces of the patient, the analyst's transformation of his own thoughts or ideas into images following a regressive path opens the way to the representation from which his intervention will have the possibility of creating successive "becoming conscious" for the patient on the pattern of hallucinatory repetitions of the traumatic event, in the immediatly of perception and according to the dream pattern of traumatic neurosis". Therefore, when dealing with adolescents suffering from a crisis of mental representation, who fall into a representative void, the attention of the therapist in this delicate phase should be directed at the indication of perceptions, of sharable images, as a possible alternative path to the failure of word-presentation. Consistent with the theoretical model of trauma I have adopted, the normal "becoming-conscious" (Das Bewusstmachen) that occurs in a transference neurosis in which the analyst's interpretation enables the removed thing-presentation to reach the preconscious word-presentation is an impracticable path for these traumatic traces.
In particular, the integration of the trauma in the systems of representation occurs by using the support of the analyst's mental image that elicits in the patient subsequent moments that become conscious, along the lines of the hallucinatory repetition of the traumatic event. From this point of view, a euristic mental functioning of the analyst could be to carry out the same work that in the traumatic neuroses the dreamer carries out in own repeated dreams.
I feel that during the first clinical encounter with the seriously traumatized adolescent, hearing the expressions of the trauma depends on the analyst's ability to transform his own thoughts or ideas into mental image, into pictorial representation in the here and now of that session. The analyst cannot have access to this mental functioning unless he carries out a formal regression of his thought: a happening that normally occurs during the condition of floating attention.
I would underline how these patients, i.e. Antonella and Angela, do not often suffer from a loss of memories of their own traumatic experiences as relative memories of the trauma are ready to become conscious even if without adeguate emotional components. They are faced with the terrifying affects of the loss of representation, whose main characteristic is its unrepresentability, and the visual pictures are a way to inhibit the production of these unpleasant affects by shifting their energy onto the "sensory force" of the pictorial representation (Freud, 1932). The pain, previously hidden by the "sensory force" of hallucination, will reappear supported by pictorial representation of the analyst and can develop into working-through.
The intervention of the analyst can remain at the level of perceptual identity, as in the cases of Antonella and Angela, or lead to storytelling, as in the case of Stefania. The transformation of thoughts or ideas into images in the analyst's mind following a formal regression of his thought, nevertheless forms part of the analytic process and is a valuable instrument for moving it forward. It is sometimes the only way to reach certain areas of the psychological life of the patient.
In the presence of the traumatized adolescent, who cannot think about or represent the trauma, who transfers it to the environment, the therapist's mind can only offer space to imagine, to construct visual mental representations and to link them to situations and affects in relations to that trauma.
Reflecting on the expressions of the trauma in the first session with our patients, I found the words of Banana Yoshimoto in her book "Shirakawa Yofune" (Deep Sleep,1989) extremely evocative:
"That evening Shori talked about his job much more than usual ... 'You know, I have to stay awake all night. Imagine if the guy who sleeps next to me opened his eyes and found me there sleeping like a log: my job wouldn't mean anything anymore. It wouldn't be professional, you see? The other person can't in any way feel alone. The people who come to me, obviously presented by someone else, are all people of a certain position but are all especially sensitive, with some wound inside. They are under such strain that they aren't even aware of being so. So, almost without exception, they wake up at night. And in that moment, in the shadow, it is important that I be ready with a smile, and perhaps a glass of water ... They usually relax then and fall asleep again. I think that everybody only wants to sleep next to somebody... Unfortunately, though, I am not good enough and sometimes I fall asleep. And you know, sleeping next to such stressed people, matching my breathing to theirs, maybe I end up absorbing all the darkness they have inside. Sometimes I tell myself that I shouldn't fall asleep, but I doze off and have frightening, surreal dreams .... I wake up with a racing heart, frightened ... And looking at the person asleep next to me, I think: But certainly, what I just saw was his mental landscape. And if I think about the desolate, painful, brutal visions that that person carries inside ... it scares me.'"
The chapter focused on that particular dimension in the first sessions which occurs in the moment when the trauma manifests itself and begins to occupy space in the mind of the traumatized adolescent in the presence of the therapist. I underlined how the trauma is not remembered in adolescence, but really discovered in, and sometimes only propped up by, the therapeutic relationship. Therefore, the traumatized adolescent expresses the trauma if the analyst considers the importance of his countertransference responses and, in particular, the support of his own mental images in the here and now of the session. That is to say, transformation of his own thoughts or ideas into mental image following a formal regression of thought, allows the therapist to maintain the cathexis to the patient suffering from a crisis of mental representation and to preserve his own capacities of representations. This hypothesis illustrated with three clinical illustrations.
Monniello Gianluigi, M.D. is Child Psyciatrist, Psychotherapist, University "La Sapienza" of Rome. Coordinatore Servizio Adolescenza, Dipartimento di Scienze Neurologiche e Psichiatriche dell'Età Evolutiva. Via dei Sabelli, 108 - OO185 Rome, Italy
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