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.
Following an expression of Freud (1914) about the transference, I suggest that the trauma is not remembered or reconstructed in adolescence, but really discovered and sometimes only propped up by the therapeutic relationship. Helping the adolescent to be interested in his inner world, to think and to reflect on himself are some of the essential aspects of clinical work with adolescents.
In the light of the concept of après-coup (deferred action), according to which the trauma takes place in two phases, the moment in which the trauma emerges and begins to occupy the mind of the adolescent occurs after the actual infantile trauma. The latter is thus intended as the silent presence of an event whose significance cannot be understood due to the state of extreme need (Hilflosigkeit) of the child. The second phase is linked to puberty and cognitive development and propped up by the parental imagos in a normal situation, but by the mind of the therapist in a pathological situation.
Following an image of Bash (1988) about the brain's functioning and the computer, I suggest that when the adolescent must deal with the external world he can only use the software that the parents offered to him.


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.
Here I refer to the pattern of trauma which accentuates the breaking of the protective shield. In this case the anxiety signal is not able to indicate the danger and mobilize adeguate defensive measures to protect the mental apparatus. This pattern has favored the development of a concept of trauma focused essentially on the problem of narcissism and the necessary time needed for the construction of the narcissistic basis of the person. Brette (1988) writes: "The quality of the maternal investment and the set of early mother-child interactions can jeopardize the formation of primal phantasies, which as symbolizing structures offer a representative aim for traumatic stimuli and their quantitative variation; the ego would therefore, be less protected from overly intense regressive tendencies and from a possible breakdown that would cause further damage. I feel it is legitimate to consider this early experience, whose traumatizing effect depends on interactive and intrapsychic experiences, as the potential avant-coup (foreaction) of future traumas." It means, in this case, that there is a failure in the early mother-child relationship, and therefore, a deficient protective shield.
This pattern is very useful in my following clinical illustrations.
First, I would briefly like to underline three concepts that are frequently used in dealing with trauma in adolescence and these are deferred action, or more exactly l'après-coup of French authors (Freud, 1914), traumatic remains (Blos, 1962) and traumaphilic need (Guillaumin, 1985). In analytic work the goal is not to repair but to re-establish the psychic time of the inner world. The time is that of the après-coup (Nachtraglichkeit). It functions in two distinct phases. This conceptualisation considers that an event which was already present wasn't, and that the new significance that arises after, produces sense about what was and that, in its turn, through this same fact transforms itself (Laplanche, 1987). This is the theory of the trauma in two phases.
Blos (1962) says that the task of the adolescence is also to arrive to save what remains of the infantile traumas. He writes: "Trauma is a universal phenomenon of childhood... therefore for the rest of his life the individual will continue to control the trauma... As regards the problem of consolidating the character, at the end of adolescence, we have to insert as part of the total process the problem of trauma... finally any trait of character owes its specific quality on the focusing of a particular trauma or on part of the trauma... the remaining traumas are the strength that push the non integrated experiences in the area of psychic life so that they can be controlled or integrated in the ego".
Guillaumin (1985) hypothesizes that the specificities and difficulties arising in the psychoanalytic treatment of adolescents often recall the existence of a kind of traumaphilic need ("d'une sorte d'appétance ou besoin traumatophilique..."). This tendency expresses an unconscious need of the adolescent to check the border of his bearable exitation. This intrapsychic process could be at the service of the mental development or could escape control of the ego and enter into the dimension of the risk of the autolesionistic consequences.
Then, about the meeting with the adolescent, the reference to the psychoanalytic cure in the therapeutic approach of adolescence is necessarily to be completed by the taking into account of all the intrinsic and extrinsic factors that interplay in the optimalization of the work contrivance. Some characteristics of adolescence (economic system of crisis, topical rehandling of the "new dependency", natural status of transference introjections) contribute to cast a light on the sometimes crucial stake and the dynamic potentiality specific of the encounter with the adolescents. The assessment, which is sometimes instantaneous and reciprocal, cannot easily be dissociated from the identifying process (Donnet, 1983). As regards the first therapeutic approach with the adolescent, two specific techniques are described that consider the dependence conflict to engage the patient in psychotherapy (Barish, 1971). Also the crucial elements of the therapeutic interaction with severely disturbed patients often revolve around the transference-countertransference axis (Giovacchini, 1985).
Then the first session is marked by its dimension of take it or leave it that are at stake for both the adolescent and the therapist (Donnet, 1983; Novelletto, 1985; Gruppo Romano di Studio dell'Adolescenza, 1988). In particular, can this session become an attractive force or sign that makes the traumatized adolescent interested in continuing the therapeutic experience ?
Is it possible that the trauma could be worked through ?
Various scenes pass through the mind of the therapist. He is waiting to know what happened, and which trauma is the origin and the cause of the disturbance. Sometimes the trauma is too evident, sometimes only hypothesized, and othertimes stimulates many hypotheses in the absence of data. All this activates the therapist's mind, and he begins to ask questions. With this, he could also not become involved too much. The wish to explain and interpret the symptoms which caused the pathological effect of the trauma remains a strong motive which is not without risks.
Chan (1991) writes: "It is lucky that the adolescent can utilize the external object, or better still its representations, as a decisive role in its new attitude, in the balancing of cathexis and countercathexis... and to use it in a determined way for his new object choices and for his new identifications."
Finally, in order to circumvent the difficulties and sometimes mortified confrontations, with the severely disturbed adolescent it seems important to open one's mind to the lateral forces which very preciously are brought into play as forms of anaclisis: lateral cathexis, splitting of transference on the setting and lateral transference are, then, useful concepts (Duparc, 1988).
I chose all these concepts because I thought it helped me to take a more satisfying position in my work with these patients.


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.
Antonella is the only child of a single, teenage (17) mother. For her first years she lived with her maternal grandparents because her mother could not provide sufficient care.
I saw Antonella in consultation when she was 16 because of hetero-and-autoaggressive behavior and progressive isolation.
Antonella is a cute girl, dressed in somewhat childish fashion, with a lively, intense gaze. Upon entering the room her gaze hurriedly swept the room, seeming to look for something to hang on too, as if she feared she would lose her balance. I imagined a child who desperately wants to run and move, but is held back by the uncertainty of her ability to walk, and therefore seeks out visual supports with her gaze.
Antonella sat down only after I tell her to and she says: "I'm here because it is good to talk. I'm not behaving well and I'm not feeling well. Before the accident I was different, happy, good and kind. My mother told me I was in a coma for a long time. It was as if I was dead. I didn't move, I didn't talk. Like in a dream I heard my mother's voice, the doctors and the pain of the injections. They were close to me but I couldn't talk to them. One day I saw my mother go away. I was frightened and tried to call her, shouting with all my strenght and again I could speak. She finds it difficult to talk and I feel the effort she makes to put her thoughts together. When she begins to talk her left leg trembles. She notices and she angrily says: "Look, I continue to tremble, I'm not able to run despite all the exercises I'm doing. I can't bear it and I can't bear not being good at school."
I find myself seeing the slow-motion images of a car accident first seen in a TV film. She stops and begins to cry. I try to confort her, but at the risk of intruding, by saying how painful and confusing it must be to relive the images of the accident. She is silent for several minutes. Then suddenly, and in crescendo, Antonella talks about all the voices in her head from which she cannot escape, and her theories about her accident. "Before, I was always laughing, often went out with my friends who were older then me. We secretly went dancing in the afternoon. I liked meeting boys giving them a date... The boy in the car with me I had met recently. That day we had kissed and touched each other."
She looked at her hand, showed it to me, and said: "Look, it's smaller then the other one. It's the hand that touched him, right there. It became infected, just as I am inside because he trasmitted something bad with his saliva..." In crescendo she continues to describe the "voices," voices of anger that push her to scratch cars, to be aggressive and to hurt herself. Antonella sat down, calmer now, and said: "I can see you are a good person...Since the accident there are many things I can't remember. Could you help me to remember ? I tell her there are many things that we can begin to see together.

The central point in this first session with Antonella seems to be when describing the accident in an hallucinatory fashion she entered the trauma. The moments of silence that followed seem to evoke the paralizing anxiety of the sudden violence. It is connected whith the impossibility of expressing her own emotions and thoughts. Perhaps she felt that during her coma, but more likely it indicates a crisis of mental representation, and thus the fragility of her narcissistic foundation, which is attributable to an inadequate early affective dialogue with the mother.
With efforts at recontructing (Robert-Pariset, 1987) directed to protect her from fragmentation and mental breakdown, Antonella tries to fill the silence with a delusion.
In the emotional crisis in which her values and representation of the self were challenged by the demands of the sexual body, Antonella had her first sexual experience just before the traumatic event. In the girl's words, these two elements (sexual fantasies and terror that the event might be repeated) seem inevitably internali del trauma di un adolescente in psicoterapia - di Daniele Biondo (original italian version)

  • La psicoterapia psicoanalitica nell'adolescenza e la formazione dello psicoterapeuta - di Marco Longo (original italian version)

  • Inner trauma and outer trauma. A psychoanalytic approach - by Arnaldo Novelletto (translation in english)
  • Trauma interno e trauma esterno. Un approccio psicoanalitico - di Arnaldo Novelletto (original italian version)

  • Working through in adolescence - by Arnaldo Novelletto (in course of publication)



    Adult Age
    independence and responsibility

    Old Age
    wisdom and decadence

    the big separation


    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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