Adolescent psychopathology and the death of meaning in psychiatry

While Professor Jureidini (2012) rightly urges psychiatrists to explore the meanings of patients’ behaviours, he ignores the psychodynamic foundations of the narrative frame that can contribute to understanding such meanings.

Professor Jureidini’s case vignette tells of Zoe, an adolescent, whose father left the family when she was a toddler, returned after many years, only to leave again. Soon after, Zoe overdoses following the breakup of a ‘benign’ relationship with a boy. Professor Jureidini involves Zoe’s mother, who had not recognised Zoe’s unexpressed distress about father; mother responds empathically, and Zoe improves. Professor Jureidini urges psychiatry to understand the meaning of Zoe’s overdose as a reaction to abandonment by father, rather than merely as a clinical sign of depression.

This formulation, while valid, involves a premature closure of the search for meaning. A psychoanalytic perspective, properly applied, may open the psychiatrist’s mind to a range of possible new meanings of the patient’s words, behaviours or experiences.

From a psychoanalytic perspective, a particular behaviour may have many meanings depending on the person’s biological makeup, developmental experiences, current relationships, life-cycle stage, and the interpreter’s framework. Conversely, outwardly different behaviours may share a similar unconscious or unexpressed meaning.

The psychodynamic paradigm of grief, which Professor Jureidini neglects, describes protean manifestations of the response to loss across the life cycle, including disturbances in affects, bodily states, moral outlook, and crucially in adolescents, disturbances of identity formation.

Furthermore, while Jureidini’s understanding may partly explain the meaning of Zoe’s overdose, it does not explain why she took an overdose rather than talk to her caring mother or a friend, i.e. it ignores what philosophers term the ‘meaning of meaning’, and its unconscious referents (Ricoeur, 1974), including the intertwined psychodynamics of love, hate, grief, sexuality and death (Schneider, 2002).

The formulations which I offer below are necessarily speculative, derived from applying a psychodynamically-informed developmental model to Jureidini’s brief vignette. In clinical practice, the psychiatrist offers the patient his/her empathy, reflections and thoughtful questions to clarify and deepen their shared understanding of the possible meanings of what the patient says or does. In turn, the patient’s responses suggest to the psychiatrist what aspects of the always provisional formulation should be discarded, modified or explored further. Of particular relevance are those that refer to the patient’s emotionally-laden experiences in an interpersonal context, including those with the psychiatrist. Such a way of working need not be confined to formal psychotherapy, but may be applied by psychiatrists in a general psychiatric context to understand their patients in a way not possible with the symptom-based checklist approach of the contemporary DSM/ICD.

Why did Zoe not confide in mother?

Professor Jureidini involved the mother to support Zoe, with an apparently successful outcome. Such an intervention, he correctly argues, follows from understanding the meaning of Zoe’s distress beyond the diagnosis of depression. A psychodynamic perspective adds additional clincially-relevant possibilities. While seeking to resolve her likely ambivalence towards father, who had recently let her down again as he had when she was three years old, teenager Zoe was also separating-individuating from mother. This raises the possibility that she feared losing mother’s love and respect because: (a) as the vignette indicates, mother was still clearly angry and derisive about father; (b) a degree of ambivalence towards mother, including mother’s body, is a normal aspect of an adolescent girl’s identity; (c) clinical experience shows that when parents separate and father leaves the family home, a child may consciously or unconsciously blame himself or the mother regardless of the adults’ ‘objective’ explanations for the separation. The child’s feelings of guilt and blame may be exacerbated years later when he or she experiences another separation or loss.

These factors might have amplified Zoe’s fear of mother’s displeasure were she (Zoe) to express grief over father’s most recent betrayal, and contributed to her reluctance to confide in mother. The relevance of these possibilities may be assessed in a therapeutic relationship, but the possibilities themselves reflect a psychodynamically-informed understanding of the meanings of patients’ experiences.

Involving mother and absent father

From a psychodynamic perspective, the possible meanings of what didn’t happen in a relationship may be as important as understanding what occurred. For example, why mother did not notice Zoe’s distress? A psychodynamic assessment of mother would include tactful inquiry about a possible childhood history of parental neglect or abuse, and hence the possibility that her self-worth required her to strive to be a better parent to Zoe than her own parents had been to her. If this proved to be the case, her failure to be aware of Zoe’s distress, or Zoe’s reluctance to confide in her, suggests caution is needed before proceeding with a joint mother–daughter session. The psychiatrist may need to assess the risk that their mutual guilt might cause Zoe to overdose again or to escalate her distressed behaviour (i.e. an iatrogenic deterioration). As it happened, the meeting between Zoe and mother was successful, but the emotional dynamics of their relationship remain unclear.

We also know nothing about Zoe’s father and their relationship or the parents’ marriage, but a psychodynamic family perspective based on the above formulation might lead the psychiatrist to inquire from mother if her earnest intentions to be a good parent might have made her then- husband feel that she had become less involved in their marriage? This might lead to questions about his childhood, including experiences of parental loss or neglect, which may be relevant to understanding why he abandoned his young family. Even though the parents’ marriage is long over, the psychodynamic frame may help Zoe and mother understand themselves, each other, father, and their history in new ways, rather than remaining haunted by rigid, moralising stereotypes of self and other (Doidge, 2007).

The boyfriend

Psychodynamic clinicians have observed that a teenage girl may use a sexual relationship to resolve her conflict of loyalties towards her parents rather than it representing an expression of her emerging sexual identity. We don’t know if this applies to Zoe, or why Professor Jureidini minimised the relevance of the relationship with the boyfriend. A psychodynamic perspective considers a relationship not only in its own right, but that its dynamics may repeat or attempt to resolve another, emotionally relevant one. We are told that the boyfriend was a kindly lad, and that their relationship was ‘benign’, the implication being that sex may not have been a vital aspect. Does this suggest that the boyfriend represented an alternative attachment figure for Zoe, shielding her against her unspoken fear that she might lose both mother’s and father’s love? Might it indicate that in her relationship with men Zoe seeks to avoid certain feelings that still trouble her in her relationship with her father? Only thoughtful conversations with Zoe over time might clarify these possiblities, but without the psychodynamic frame the psychiatrist may not listen for these themes in Zoe’s story or fail to ask relevant questions.

The overdose

Psychodynamically-informed clinical observations report that aggressive, emotionally-laden enactments, rather than a capacity for reflective discussion, typify a toddler’s response to a loss felt as threatening the continuity of the psychological self (Fonagy and Target, 1996). This resembles what adolescent Zoe did. So was she enacting an angry, despairing protest in attacking her body by overdosing? A psychodynamic perspective might formulate this behaviour as a regression to ways of thinking and behaving typical of an age when Zoe had ‘lost’ both parents (Westen et al., 1990); for when she was a toddler, father left, mother grieved and was also preoccupied with Zoe’s baby brother. A psychodynamic perspective would inquire what role anger and aggression played in Zoe’s overdose.

Identity

The clinical implications of psychodynamic thinking alerts us to consider three clinically important possibilities about Zoe’s identity development:

• That unresolved distress and anxieties involving attachment, aggression and sexuality may still trouble her.

• In apparently resolving her distress with mother’s help about father’s recent betrayal, Zoe might now arrest her adolescent separation-individuation task, and become the kind of daughter she believes mother needs her to be – conscientious, non-assertive, studious and non-sexual, i.e. a false-self (Winnicott, 1965).

• She may be vulnerable to seeking similar qualities in a boyfriend (i.e. a narcissistic love), or avoid relationships with men altogether.

The psychiatrist who keeps these possibilities in mind might not consider the therapeutic task completed merely because Zoe reported feeling better or mother was satisfied with Zoe’s behaviour.

The future

Psychodynamic clinicians have described adult patients who are apparently emotionally stable, socially conforming, and high functioning, but become mentally unwell in mid-life, in what psychoanalysts refer to as the third separation-individuation phase (Oldham, 1989). Why at this time of life do such people become depressed, misuse alcohol, gamble, abandon their careers or pursue idealised extramarital relationships? In the context of psychodynamic therapy such patients sometimes become aware of their resentment that their self-worth has always required them to be dutiful and accommodating to the needs of others, to attain high social status or achieve financial or academic success. Their resentment may be compounded by a double identification: with the mortality of their own parents, and with the perceived ‘selfishness’ and freedom of their adolescent children. These considerations may be relevant to Zoe were she to become depressed again in adult life. A psychodynamically-informed narrative may enable her to recognise herself and others in ways that provide credible, meaningful alternatives to the justifications she habitually uses to account for her actions or for distress and disappointments in her life.

Meanwhile, contemporary psychoanalytically-informed political narratives describe the world adolescent Zoe faces. It is one where shared social meanings and values are lacking, and where her role in the social order is merely that of an indocrinated consumer of commodities, a node at the confluence of communication networks, impersonal bureaucracies, and economic forces which she neither understands nor can influence. Rationality in this post-modern world of global capitalism means learning to be reconciled to one’s powerlessness, or seeking solace by consuming more products or by vicarious identifications with ‘celebrities’ on Facebook. In reaction to this, religious fundamentalist movements or secular global conspiracies offering eschatological certainty may hold great appeal (Jameson, 1991), especially to an alienated or suicidal teenager in search of identity or personal meanings. Psychoanalytically-informed moral philosophy (Nussbaum, 2004) highlights the fragility of our democratic ways of thinking and the unconscious influences on the respect for justice which a society imparts to the younger generation.

Nor are psychopathology, an empty marriage or alienation the only possible outcomes for Zoe. Psychoanalysis has long studied the influence of loss and trauma on creativity (Rose, 1987), and described special configurations of female creativity, typified by ‘the sensual mothers of humanity’ (Kristeva, 2001).

Over the past 20 years, this vast, rich and evolving tradition of clinical wisdom and scholarship has been extirpated from Australian psychiatry in the name of mental health reform. Today, society believes that psychiatrists mostly diagnose and prescribe medication for chemical imbalances in the brain. Psychiatrists learn little of how psychodynamic narratives elucidate meanings in general psychiatry (Holmes, 1994), consultation-liaison psychiatry (Viederman and Perry, 1980), and the burgeoning fields of narrative medicine (Rudnytsky and Charon, 2008), attachment theory (Fonagy, 2001) and neuroscience (Doidge, 2007).

Cognitive behaviour therapies don’t conceptualise or explore how personal meanings, emotions, relationships, and a person’s body are imbricated with their developmental and family histories across the generations in various contexts to create a sense of self (Fonagy, 1999), nor how such meanings may render people vulnerable to suicide even when they don’t display typical features of clinical depression or psychosis (Malstberger, 2004), or how such meanings influence the doctor–patient relationship (Balint, 1957) and the group dynamics of a multidisciplinary team or ward staff (Gabbard, 1992).

No one knows the extent of unnecessary suffering such ignorance may have caused patients, their families and clinicians in a mental health sytem whose architects advocate the diagnosis and brief treament of illness ‘episodes’ and strategies devoid of meaning to prevent relapse. Beyond serious clinical, ethical and moral considerations, such ignorance may have political consequences for our profession, which the psychoanalytically-informed political philosopher, Habermas, termed a legitimation crisis (Habermas, 1973). Yet some persist in ridiculing psychodynamic approaches, for by triumphantly asserting that nothing of value has been lost in the reform process, the mourning and reparation entailed by admitting one’s ignorance and seeking professional re-education remain unnecessary (Winnicott, 1958).