Psychodynamic psychotherapy for adolescents

Psychodynamic psychotherapy for adolescents

Psychodynamic psychotherapy for adolescents 17 Dana Atzil-Slonim Psychology Department, Bar-Ilan University, Ramat Gan, Israel According to the Wor...

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Psychodynamic psychotherapy for adolescents

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Dana Atzil-Slonim Psychology Department, Bar-Ilan University, Ramat Gan, Israel

According to the World Health Organization (2013), 20% of all adolescents, globally, experience a mental health problem every year. Adolescents’ mental health problems have important implications for all facets of their lives, including their ability to study, engage in social life, and find their own way in the world (Midgley, O’Keeffe, French, & Kennedy, 2017). Adolescent psychotherapy research has advanced considerably in the last two decades (cf., Midgley et al., 2017), but compared to the abundance of literature on adult psychotherapy, adolescent psychotherapy still lags far behind. Adolescence is a period of transformation from childhood and preparation for adulthood. It is a developmental period characterized by a large number of biological, psychological, and social changes. The combination of these factors makes this period extremely important yet also very challenging. Psychodynamic theoreticians have described the developmental challenges that characterize this phase as well as the possibilities for growth and change through psychotherapy for adolescents who experience difficulties during this critical stage of development. This chapter focuses on adolescent psychodynamic psychotherapy. The first part of the chapter provides a brief overview of psychodynamic theories of adolescence, from the early days of psychoanalysis to more contemporary views. The second part of the chapter describes psychodynamic psychotherapy in practice. The third part of the chapter reviews recent findings from psychodynamic psychotherapy research on adolescents. The fourth part of the chapter includes a short case illustration, which describes the process of change of one adolescent in psychodynamic psychotherapy.

Psychodynamic theories of adolescence Psychodynamic psychotherapy with adolescents draws on psychoanalytic ideas while integrating concepts from other disciplines, including developmental psychology and attachment theory (Lanyado & Horne, 2009). Although the term psychodynamic psychotherapy covers a range of approaches, most share the central idea that the adolescent’s problems make some kind of emotional sense. Their roots lie in the internal world of adolescents that builds up from their earliest experiences and relationships. Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00017-9 © 2019 Elsevier Inc. All rights reserved.

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Classical psychodynamic perspective of adolescence Classical Freudian theory paid relatively little attention to adolescent development and discussed it solely in terms of psychosexual development. In “Three Essays on Sexuality,” a chapter devoted to puberty, Freud (1905) described adolescence as a period of transition between diffuse infantile and genitally centered adult sexuality. According to Freud, the main events in this process are the subordination of the erogenous zones to the genital zone, the setting up of new sexual aims (different for males and females), and the finding of new sexual objects outside the family. Anna Freud (1958) further developed these ideas and described the adolescent as primarily engaged in an emotional struggle of extreme urgency and immediacy. In her view, the threat to ego integrity derived from both the strength of pubertal drives and the regressive pull toward the objects of infancy and childhood. Her emphasis was on adolescent defenses that protect the ego from being overwhelmed by anxiety caused by the impulses of the id and love objects in the individual’s oedipal and preoedipal past. Blos (1967) amplified one of Anna Freud’s themes by emphasizing the way in which the adolescent disengages from the internalized love and hate objects of childhood in order to find extrafamilial love and hate objects in the external world. Blos defined his concept of adolescence as a second individuation process in which the adolescent sheds family dependencies and loosens infantile object ties to become an individuated adult member of society. Throughout this demanding process, the adolescent longs for comfort from infantile objects but at the same time fears reinvolvement with these objects. Blos viewed ego regression as an essential component in the progressive development of the adolescent. Erikson (1968) described adolescence as the period during which the individual must establish a sense of personal identity. Adolescents must find answers to questions about where they came from, who they are, and what they will become. The rebellion against parents that characterizes this period is intended to help adolescents clarify their distinct identity. During this period, the peer group serves as a key important factor in helping adolescents formulate their own identity and define who they are. The need for extrafamilial relationships to cope with transformation in relationships with parents is emphasized as well in the self psychology literature on adolescence. Following Kohut’s lead, Wolf, Gedo, and Terman (1972) suggested that one of the most upsetting and painful processes of adolescence is the transition from the need to have the parent function as an idealized selfobject (a figure whose presence, power, wisdom, or goodness contributes to one’s sense of self) to disillusionment with the parent as an ideal. Parallel to adolescents’ growing ability to view their parents more realistically, there is a need for substitute idealized selfobjects such as peers, cult heroes, and ideologies. Winnicott (1971) broadened the idea of the evolving experience of self in adolescence and the importance of the surroundings in its development by relating to adolescence as a world unto itself with its own unique dynamics. His main emphasis was upon acknowledging the authenticity of the troubling and distressing

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psychological states that emerge during this period of life. According to Winnicott (1971, p. 146), adolescents “struggle to feel real” and reject society’s false solutions: “Immaturity is a precious part of the adolescent scene. In this is contained the most exciting features of creative thought, new and fresh feelings, ideas for new living. Society needs to be shaken by the aspirations of those who are not responsible”. Winnicott also highlighted the function of aggression and destruction in the maturational process. If the other survives without retaliating or withdrawing under attack, the adolescent can start to know the other as a person with his or her own subjectivity. Relational psychodynamic theoreticians have further developed Winnicott’s notions and emphasized the importance of the object’s survival in the face of adolescents’ destruction (e.g., Benjamin, 1995). According to Benjamin (1995), when an adolescent’s destructiveness damages neither the parent nor the self, external reality comes into view as a sharp, distinct contrast to the inner fantasy world. The outcome of this process is not simply reparation or restoration of the good object, but love, the sense of discovering and recognizing the other.

Contemporary psychodynamic perspective of adolescence The more contemporary relational perspective of adolescence (e.g., Briggs, Maxwell, & Keenan, 2015; Levy-Warren, 2000) differs in several ways from earlier psychodynamic views.

The centrality of relationships The relational perspective emphasizes that development occurs through participation in an expanding series of interpersonal fields. While the classical psychoanalytic view tends to emphasize that the main goal in adolescence is to achieve autonomy and independence (Schafer, 1973), the relational theory views individuals as interdependent at every stage of life and posits that only the dimension of connectedness evolves. The internal representations of the child parent relationship and the relationship itself are continuously revised and reorganized throughout childhood. Adolescence merely continues this process at an accelerated pace. Individuals who successfully traverse adolescence still need and make use of the continuing relationship to their parents but need less frequent direct contact and help and are more capable of using the parental relationship as an inner resource. Therefore the adolescent’s assertive desire to make decisions and establish greater privacy and freedom from supervision is seen not as striving for autonomy but as striving for a new kind of relating. The increased level of parent child conflicts during adolescence is seen as normative ambivalence toward change and a negotiation about the new form of relating that is being created by both parties. Thus the essence of adolescents’ new relational needs consists of being known and recognized by others at a time when the adolescents are learning to know and recognize themselves. To be known by another, one must know oneself. It is only then that individuals can be sure that what others know about them feels real (LevyWarren, 2000). Feeling known is a critical component of intimacy. Lack of

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fulfillment of the need for intimacy creates loneliness, which can be one of the most painful of all states.

Individual and contextual differences Relational theories on development take into account the multiple forces that interact and create a very different experience of growth for each individual. It is not just individual differences that determine whether adolescence is turbulent or proceeds in a smooth transition to adulthood, but rather the social context in which some groups are more vulnerable than others especially in terms of race, gender, class, and sexuality.

Multiplicity versus singularity of the self According to the relational view, progress and development are achieved through the growing ability to tolerate experiencing multiple versions of oneself alongside a sense of continuity and integrity of the self. Within this approach, psychopathology is viewed as narrowness in perception, that is, a tendency to truncate new experiences into rigid stereotyped patterns (Mitchell, 1993). Although an important component of adolescent development is defining the sense of self and relationships to know who one really is, it is equally important for adolescents to be able to move between different states of mind in their relationships to themselves and others (Briggs, 2002).

The ability to sustain negative thoughts and feelings The relational view highlights the importance of tolerating negative experiences in order to be able to change and grow (Ogden, 2005). Adolescents need to make use of the resources provided in childhood to understand, make sense of, and contain the impact of anxiety, conflict, ambiguity, and uncertainty of their ongoing internal changes. If the adolescent and the primary caregiver can tolerate the negative experiences that accompany change, the quality of turbulence is transformed (Briggs, 2002).

The struggle between the need to grow and the fear to change At every period of developmental transition there is always an inner conflict between the need to develop and the dread of change (Mitchell, 1993). In adolescence the rapidity of change guarantees that there will be some vacillation between wanting to be treated like the grown-up one is becoming and wanting to be treated like the child one does not want to leave behind. Still, in most cases, forward movement will never stop for long. When anxiety severely prevents adolescents from accessing their inner resources or if there is a persisting sense of unmet needs in past and present relationships, forward movement may be blocked. This indicates a deviation from a healthy developmental path, which may lead to the need for treatment.

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Psychodynamic practice with adolescents The psychodynamic conceptualizations of adolescence described above serve as guideposts for adolescent psychotherapy, which is one of the great challenges for therapists, since it involves formulating an intervention for an individual in transition. In adolescent psychodynamic psychotherapy the central goal is to help the teenager return to the path of normal development and mastery of age-appropriate tasks (Lanyado & Horne, 2009). To encourage optimal psychic functioning in harmony with the self and the client’s social world, psychodynamic psychotherapy aims to help the adolescent develop the capacity to tolerate painful emotions, which are known to be intensified during this period (Briggs, Maxwell, & Keenan, 2015). Successful treatment should not only relieve symptoms but also foster the positive presence of psychological capacities and resources. Depending on the adolescent and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a realistically based sense of self-esteem, tolerate a wider range of affect, understand the self and others in more nuanced and sophisticated ways, and face life’s challenges with greater freedom and flexibility. The course of psychotherapeutic work with adolescents is widely acknowledged to be difficult, ambiguous, and challenging. Adolescents contribute unique attributes to the therapy process that distinguish them from other therapy populations (Briggs, Maxwell, & Keenan, 2015). Adolescents are usually referred to treatment by parents, teachers, or counselors and rarely seek help on their own initiative. Frequently, adolescents are at odds with their referrers about what the goals of therapy should be (Kazdin, 2004). The very nature of adolescent development, which includes a tendency toward impulsive behavior rather than being reflective, often means that the length of treatment is unpredictable. Adolescents tend to have an ambivalent attitude toward treatment, and dropout rates within this age group are relatively high (Kazdin, 2004). A brief description of the main characteristics of psychodynamic psychotherapy with adolescents is provided below.

Establishing and maintaining a therapeutic relationship with adolescents Forming positive therapeutic relationships with adolescents can pose a formidable challenge to therapists (Marks-Mishne, 2010). As the young person is attempting to separate from the family, form an identity, and make important peer attachments, he or she is often reluctant to enter into a relationship and form attachments with a new adult. Some adolescents cannot enter therapy and sustain an alliance because of an overpowering wish to keep their private life private. Some are fearful of sharing sexual and masturbatory fantasies. Others are mortified by shame, envy, and profound self-consciousness and are oblivious to the universality of the ageappropriate anxiety that burdens them. Fear of therapy, of a new powerful adult and the discovery of one’s inner troubled self, is generally much stronger than the wish

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for assistance. Many authors concur that significant modifications of technique are usually necessary in applying psychodynamically oriented psychotherapy with adolescents (e.g., Lanyado & Horne, 2009; Marks-Mishne, 2010). For example, the unstructured invitation “to say everything that comes to mind” and a passive silence during the therapeutic hour may be anxiety-provoking for adolescents. Often, therapists take on a more active role in treatment with adolescents than they would with adults (Shefler, 2000). Empathic warmth, active attentive listening, active participation, and a respectful attitude are considered essential to the formation of a positive therapeutic relationship with adolescents (Marks-Mishne, 2010).

The transference countertransference relationship In adolescent psychodynamic psychotherapy, perhaps more than in therapy for any other client population, the main crucible for new experiences is the work associated with the therapeutic relationship (Karver, Handelsman, Fields, & Bickman, 2006). The main emphasis is on generalizing the adolescent’s new experiences developed in the therapeutic relationship to relationships with others outside therapy (Levy-Warren, 2000). Through the relationship with the therapist in a consistent setting, adolescents may begin to feel able to express their most troubling thoughts and feelings. Confused, frightened, hurt, angry, or painful feelings can gradually be put into words rather than actions. The therapist can help adolescents make sense of their own experience and develop their own individuality and potential. The adolescent’s sense of who he or she is and how others will react to him or her are very much affected by expectations based on past and present family relationship. Throughout treatment the transference countertransference relationship becomes a representative sample of adolescents’ ways of relating to the people who are important to them. As a result, specific anxieties and painful conflicts come alive and can be worked with, sometimes at first within the contained context of the therapeutic relationship. The emotional changes resulting from the working through of these issues gradually become more generalized and a part of the adolescent’s repertoire in everyday relationships (Lanyado & Horne, 2009). Many other aspects of ordinary developmental processes can be experienced within the therapeutic relationship. For example, a patchy pattern of attendance at therapy in which helpful and fruitful sessions are interspersed with sessions missed without explanation may express the back-and-forth dynamic of the need to gain more autonomy while staying related in the relationship with parents as well as the internal war between wanting to move forward and wanting to stay the same. Adolescents often elicit complex feelings and reactions in the therapist because of the tensions and ambiguities that characterize this age period, which involve mixed emotions, thoughts and actions about separateness and intimacy, independence and dependence, the need to grow and the fear of change—all of which can become easily confused and confusing (Briggs, Maxwell, & Keenan, 2015). In working with adolescents, an important path to the heart of the work, in which new possibilities for listening and understanding can arise, is through the therapists’ analysis of their own countertransferential responses. The exploration of the

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particular qualities of the transference countertransference relationship helps the therapist know more about the client’s fantasies, relationships, functioning, and expectations. In this way the therapist’s emotions and reactions to the client are viewed as valuable assets in providing guidance to deal with taxing treatment dilemmas. Commonly, a frank and nonanxious examination of feelings facilitates the resolution of various therapeutic impasses (Lanyado & Horne, 2009). The most important growth that leads to deep change in the client’s relationships and internal world is gained from what happens in the consulting room, in the here-and-now of the meeting of two people: the therapist and the adolescent. It is important to bear in mind that alongside the transference countertransference relationship between the client and the therapist, there will always be a real relationship between them, as reflected in the degree to which each is genuine with the other and perceives the other in ways that befit the other (Gelso, 2011). Adolescents need the therapist to be a separate object with whom they can identify and negotiate their evolving separate identity (Erlich, 1993). Therapists cannot replace the significant others with whom adolescents live their lives. However, they can provide a new relationship experience that can be generalized and open up new possibilities with others in the adolescent’s world, particularly with regard to parents.

Anxieties and defenses Anxieties in adolescence can stem from a variety of sources including the changing body, the need to redefine the sense of self and identity, the need to redefine old and present relationships, and the need to create intimacy. Increased anxiety leads to the use of a range of defenses, some of which are considered more adaptive while others can be destructive, depending on the extremeness and rigidity in which they are applied. When distressing feelings come alive within the therapeutic relationship, treatment can sometimes be painful. In working with defenses in therapy, there are two aims: to explore the defenses that are neither age appropriate nor helpful and to increase the range of appropriate defenses available to the adolescent for coping with unbearable anxiety or emotional pain. In addition, anxiety—in all its irrationality—needs to be faced gradually and made sense of within an attentive, holding relationship (Horne, 2001).

The dialectic between internal and external worlds The dynamic interaction between people’s experience of their internal world and the external world, which includes the client’s real relationships outside therapy, is pivotal in psychodynamic psychotherapy with adolescents. Obviously, the internal and external worlds affect each other. The external world is perceived through the eyes of the internal world filter, which in turn is affected by what has actually happened in the external world. In a traditional, open-ended, psychoanalytic treatment the outside world is often in the background; however, in therapy with

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adolescents, family dynamics are frequently so complex and intertwined that to treat this age group effectively, therapists must be open to the possibility that involving the family might at times be not only recommended but absolutely essential to facilitate an effective outcome (Cohen, 2005). This requires the therapist to find a balance between the opposing but complementary forces of the individual and the family. Both parents and adolescents oscillate between separation and maintaining closeness, between wanting to find new ways to relate and wanting to stay the same. If the therapist can help the adolescent tolerate experiences of uncertainty, anxiety, change, and ambiguity—and if the adolescent’s environment can be encouraged to support this process—the quality of internal and external conflicts can be transformed (Briggs, 2002). Since internalization processes are still under construction and the real objects are very present in the client’s life, changes achieved through psychotherapy with adolescents can have a crucial influence both on the consolidation of internal representations and on actual relationships, especially with parents.

Psychodynamic psychotherapy research on adolescents Research on adolescents’ psychodynamic psychotherapy has advanced considerably in the past two decades (cf. Midgley et al., 2017). This is particularly noteworthy because adolescent therapy research, in sharp contrast to research on adult psychotherapy, received little attention for many years. Recent reviews of the literature (Abbass, Rabung, Leichsenring, Refseth, & Midgley, 2013; Midgley et al., 2017; Palmer, Nascimento, & Fonagy, 2013) underscore the effectiveness of psychodynamic psychotherapy for adolescents for a wide range of disorders. These reviews also suggest that adolescents with emotional or internalizing disorders seem to respond better to psychodynamic psychotherapy than do adolescents with disruptive or externalizing disorders. Adolescents with more disruptive disorders are more difficult to engage and more likely to drop out of psychodynamic treatment, but there is evidence that when they engage in treatment, it can be effective and that the frequency of treatment may be important. Another consistent finding is the notion of a sleeper effect, in which the gains from therapy continue to increase after the end of therapy. Effectiveness studies constitute an important step in confirming the validity and usefulness of psychodynamic psychotherapy for adolescents. However, researchers have argued that to better understand how and why psychodynamic psychotherapy works, relying solely on effectiveness studies would be accepting too narrow a definition of research (e.g., Kazdin, 2004). This has triggered a heated debate on the methodologies needed to better study what works for whom in psychodynamic psychotherapy for young people (e.g., Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002). The key issue is how to investigate the complex processes that take place in psychodynamic psychotherapy with adolescents that can lead to change, so that what goes on in treatment itself can be related to changes in outcome. In the field

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of psychodynamic psychotherapy for adolescents, relatively few studies have conducted process analyses or attempted to link specific processes derived from the psychodynamic theoretical model to outcomes, but those that have done so show great promise. For example, Di Lorenzo, Maggiolini, and Suigo (2015) examined the typical features of adolescent psychodynamic psychotherapy as compared to other adolescent psychotherapeutic approaches in terms of the therapists’ responses to adolescent clients. Their results indicated that the therapeutic process was characterized by prioritizing helping adolescents make sense of their own experience by focusing on current relationships and emotions rather than on past relationships. In the IMPACT-ME longitudinal research project led by Nick Midgley, qualitative interviews were used to better understand the quantitative results. For instance, one substudy examined hopes and expectations from therapy among depressed adolescents and found that differing expectations were likely to have implications for the way in which young people engage with treatment (Midgley et al., 2016). In another study, Fernandez, Krause, & Pe´rez (2016) investigated the role of the quality of the therapeutic alliance in the first sessions and therapeutic outcomes of adolescent psychotherapy to assess which perspectives (those of adolescents, therapists, or parents) and which times of evaluation (first, second, or third session) had greater impact. The results showed the importance of the initial construction of the working alliance by both the adolescents’ and the therapists’ perspectives. Wright, Briggs, and Behringer (2005) examined the association between attachment styles and suicidality among adolescents in psychodynamic psychotherapy and found that high-risk adolescents tended to communicate their distress in therapy in a more preoccupied/enmeshed manner. Another process-outcome study reported an association between an increase in the flexibility of interpersonal patterns and a decrease in symptoms among adolescents in psychodynamic psychotherapy (Atzil-Slonim, Shefler, Dvir-Gvirsman, & Tishby, 2011). Despite these significant advances in the field of adolescent psychodynamic psychotherapy research, we still know far less about what works for whom than is the case in adult psychotherapy research. Prominent researchers in the field consistently highlight the need for more studies to further explore the process of psychodynamic psychotherapy for adolescents and determine which mechanisms lead to positive outcomes that can help adolescent clients return to a healthy developmental path and expand their freedom and choices (e.g., Kazdin, 2004; Midgley et al., 2017).

Case illustration The following example illustrates the processes of change of one adolescent client over 1 year of psychodynamic psychotherapy. This case was chosen from a larger sample of adolescents in psychodynamic psychotherapy, in which clients went through in-depth interviews according to the Core Conflictual Relationship Theme (CCRT) method (Luborsky & Crits-Christoph, 1998) at the beginning of treatment and a year later (for further details, see Atzil-Slonim, Shefler, & Tishby, 2015).

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Client description and presenting problem Ahmed, a 16-year-old male Israeli Arab, was referred for treatment by the school counselor because his level of functioning at school has declined significantly. Ahmed was diagnosed with moderate depression. In the intake meeting he said that in the last few months he had gradually realized that he was homosexual. He felt that he could not disclose this to his parents, since they are religious Muslims and would not accept it. Ahmed felt caught in a complex dilemma: He felt obliged to choose between a life of conformity to his parents’ values, which would mean negating who he really was, and being true to himself but hiding his true nature from close friends and family. His struggle to establish a sense of personal identity (Erikson, 1968), along with age-appropriate conflicts in the relationship with his parents, exceeded tolerable levels of distress, leading to treatment referral. The course of treatment is described through the relational narratives the client told about meaningful interactions during psychotherapy, at the beginning of treatment and 12 months later.

Ahmed’s CCRT at the beginning of treatment Relationship with mother, first interview: Mom calls my cell phone in the afternoon. She asks how I am, if I did my homework and what my plans are for the rest of the day. I can’t tell her where I really am, because I’m going to a meeting at the “Open House” (a club for gay and lesbian teenagers). I try to end the conversation as quickly as possible, my answers are minimal. She doesn’t understand that I don’t want to talk to her and she continues snooping. I give her the answers she wants to hear and try to be as polite as I can. She doesn’t know a thing about me and I don’t want her to know. I just want her to leave me alone. Relationship with the therapist, first interview: in the last session I was telling her only good things about myself. I thought, what a waste of time, there are so many bad things that I did that I’m not sharing with her. She just listened. And then I told her things about me that are kind of good but may look not so good in the eyes of an adult. I wanted to see how she reacted to that. She continued listening, asked questions about it and she wasn’t judgmental at all. It made me feel good that she didn’t criticize me. However, it was a waste of time, because I didn’t talk about all the bad things. In these narratives from the initial phase of treatment it seems that Ahmed was mainly occupied with hiding from his mother what he was doing and thinking. He experienced his mother as invasive and not understanding, and he made an effort to avoid conflict with her. In the process of preventing himself from expressing his emotions to his mother, his emotions were apparently not available to him either. The theme of hiding versus disclosing thoughts and emotions was also present in the relationship that started to develop with his therapist at the beginning of treatment and may represent the development of transference. He described an interaction in which he tried to present something to the therapist to test whether she

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accepted it or not. Although the therapist seemed to pass the test, Ahmed was aware of how much was still hidden in the relationship.

Ahmed’s CCRT after a year of treatment Relationship with mother, second interview: Last Saturday, I was sitting on her bed while she was folding the laundry. She asked me whether I wanted a girlfriend. I felt angry with her, she really doesn’t understand who I am. For her, the idea of having a girlfriend before being married is considered being open minded. I started to reply, with the answer I thought she wanted to hear, but then suddenly I felt bad about what I was doing. I thought that I try so hard to make her happy that I don’t even hear my own voice when I’m around her. I thought to myself: “does she really want to know how I feel and who I am? Why am I trying so hard to please her?” It made me sad. Anyway, the conversation continued and we changed the subject and began talking about the fact that people can live in all kinds of lifestyles, not only the traditional style of marriage. I found myself arguing with her. I was surprised that she listened and didn’t completely reject my opinion. Then she gave an example as if she wanted to refute what I said, so she said ‘if for example a son tells his mother he is gay, she doesn’t have to accept it, does she?’ I told her what I thought about the importance of accepting people as they are. We were not talking about ourselves, only hypothetically about the subject, but I was really surprised that we could talk this way. This was actually the first time I heard her saying this word (gay), and I didn’t know it even existed in her thoughts. I was very much surprised. On the one hand she talked about it as if it was forbidden, and that really made me sad, but on the other hand it was kind of a strange feeling. . . because she raised the subject and I was sort of glad. . .not exactly glad. . .kind of excited that I could answer her and that we could talk about this subject. Of course I would have liked her to be understanding and accepting but I don’t really expect that from her. She is too religious and limited to be able to do it, but I was moved by the fact that we were both a little more real in that conversation. Relationships with the therapist, second interview: We talked about something that we have already talked about before many times. This is something I also think about a lot. However, this time I opened up about it more than in previous sessions and I told her details that I have never disclosed before. While I was talking about it with her, I started to think about it in a different way than I used to. Suddenly it didn’t sound as terrible as before. I don’t remember what she said but I remember feeling that she really accepted me despite what I did and that it’s not only because she was doing her job as a psychologist, but because she understood it as a person. It’s not that I thought that what I did was OK, she didn’t think that either, but we both knew I regret what I did and that it didn’t mean I am a bad person. I started to cry. . . I felt that she really got what I felt in that moment because she also knew what I felt about it before. I was very sad. . .it ‘s painful. . . all this time I spent hating myself for what I did. . .I cried a lot in that session. . . but at the same time

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I felt relieved because finally I let everything out and I realized I could feel different about it. Ahmed’s flexibility, reflectivity, and access to emotion appeared to increase throughout the year of treatment. Ahmed’s positive and negative internal representations toward his mother grew richer and more complex through treatment. After a year of treatment Ahmed was still feeling not accepted, angry, and misunderstood by his mother, and he still experienced himself as closed and distant. At the same time, however, new themes emerged. He expressed more willingness to accept his mother as limited because of her religious beliefs, and he experienced himself and her as a little more open, real, and authentic in the interaction. While in the first interview he described himself as holding in his anger, in the second interview he was still angry but also very sad. He appeared to have become more in touch with his inner world and better able to sustain and tolerate his negative emotions. These differences between the first and second interviews were also noticeable in the relationship with his therapist. After a year of treatment Ahmed’s narrative about the therapist included an interaction in which he could open up to his therapist about something that he had not been able to trust her with in the past that evoked feelings of shame and guilt. He described how it was possible for him to explore these emotions with his therapist and to tolerate them together. He continued to describe a moment in therapy when new ways of experiencing himself and the therapist emerged. Psychodynamic psychotherapy aims to help adolescents get to know the conscious and unconscious parts of themselves that were not previously available to them so that they can experience themselves and others more fully and have a broader range of choices in their interpersonal interactions (Mitchell, 1993; Ogden, 2005). For Ahmed the opportunity to work through his internal representations in the relationship with his therapist may have opened up new possibilities for him to experience himself and others. Therapy also made it possible for him to generalize these new experiences to the relationship with his mother and hopefully to other relationships. This process may have contributed to Amhed’s achieving clinically significant change measured with standardized symptom scales. His own words about the therapist beautifully describe the process of change: She listens and she is not judgmental about things I have done that I felt ashamed about before, and it helps me because now I can listen to myself better and accept myself as I am.

References Abbass, A. A., Rabung, S., Leichsenring, F., Refseth, J. S., & Midgley, N. (2013). Psychodynamic psychotherapy for children and adolescents: A meta-analysis of shortterm. Journal of the American Academy of Child and Adolescent Psychiatry, 52(8), 863 867. Atzil-Slonim, D., Shefler, G., Dvir-Gvirsman, S., & Tishby, O. (2011). Changes in rigidity and symptoms among adolescents in psychodynamic psychotherapy. Psychotherapy Research, 21(6), 685 697.

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Further reading Gaines, R. (1999). The interpersonal matrix of adolescent development and treatment. In A. H. Esman (Ed.), Adolescent psychiatry: The annals of the american society for adolescent psychiatry (Vol. 24, pp. 25 47). Hillsdale, NJ: The Analytic Press.