PSYCHOTHERAPY OF THE HOSPITALIZED ADOLESCENT

Abstract

Experience in psychotherapy with over 300 hospitalized adolescents is described by brief reference to several important aspects of treatment. The patient's admission to the hospital is regarded as a critical phase in treatment. Here the doctor first accepts that high level of responsibility for the patient's welfare which must be maintained around-the-clock during hospitalization, and generally continued long after discharge. This is usually required to assure the patient of continued treatment despite powerful opposing forces from within himself, his family and sometimes others. By taking care of his patient's realistic needs, without expectation of immediate personal reward, the therapist incidentally lays the groundwork for the gradual development of a relationship which is in itself therapeutic and which later actually supports verbal psychotherapy in the more conventional sense of the word. The therapist not only may, but must personally exercise needed authority over the patient. He is constantly supported in this by the supervisor of psychotherapy, who is necessarily also the ward administrator. The therapeutic hospital milieu was carefully developed with the understanding that the ego continues to shape itself against the demands of reality, and that the creation of an artificial freedom from reality is justified only in so far as the patient is genuinely unable to respond to realistic demands with personal benefit. It is recognized that there are levels and kinds of responsibility. Whatever a therapist expects his patient to contribute to his own treatment, by coping with unmodified realities, must be determined by the doctor's own best estimate of his patient's abilities. Treatment of the adolescent is a highly interpersonal process. Attention to the qualities and vicissitudes of adolescent-adult relationships is seen as the best means of understanding the processes of psychotherapy with patients in this age range. This is probably also the most useful framework in which to study the psychology of adolescence generally, as we rarely have an opportunity to observe them directly except in relationship to ourselves. We never see them in the kind of theoretical vacuum which is so often assumed in textbook discussions of them. In treatment, primary importance is attached to any efforts which foster the normal maturational processes of adolescence. Psychotherapy, though derived from psychoanalytic psychology, emphasizes measures which favor ego-synthesis without extensive analysis of infantile conflicts. Some of the universal sources of tension between the adolescent and the adult are mentioned with particular regard to resultant distortions in communication. The recognition of essential verbal and non-verbal communications is discussed as a prerequisite to successful treatment. There are many complex countertransference problems which are characteristic of therapy of adolescents, and which ultimately will require detailed study. Finally, it is proposed that adolescents, for a variety of reasons peculiar to their age, tend to compel effective treatment. They appear to be much less tolerant of ritualized treatment than adults, and because of their physical size and the strength of their drives, they can convey the magnitude and urgency of their intolerance much more impressively than the child.