Lost for Words: Difficulty Expressing Feelings in Work with Three Adolescent Boys
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| Title: | Lost for Words: Difficulty Expressing Feelings in Work with Three Adolescent Boys |
|---|---|
| Language: | English |
| Authors: | Tyminski, Robert |
| Source: | Journal of Child Psychotherapy. 2012 38(1):32-48. |
| Availability: | Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals |
| Peer Reviewed: | Y |
| Physical Description: | |
| Page Count: | 17 |
| Publication Date: | 2012 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | Verbal Communication, Nonverbal Communication, Self Concept, Males, Adolescents, Case Studies, Emotional Response, Language Impairments, Mental Disorders, Psychosis, Drug Abuse |
| DOI: | 10.1080/0075417X.2011.651842 |
| ISSN: | 0075-417X |
| Abstract: | Case material of three adolescent boys is considered with regard to thematic similarity around acts of puncture. Their non-verbal communication is seen as a symptomatic acting out of an internal loss of containment. This resulted in psychotic disorganisation in which aspects of language appeared selectively impaired. Each boy struggled to express emotions and feelings, and was at a loss for words in attempting to describe how he felt. Anzieu's concept of the containing function of the skin ego is examined, as this is a useful idea for thinking about puncture of an internal shell, and what happens when it is not able to withstand disturbing internal forces. Bion's theory of alpha function is also explored to understand further a breakdown in emotional communication. Disruption of alpha function can result in bizarre images. In each case, disturbing imagery was a feature of therapeutic breakthrough, which followed incidents of puncture in the outer world. Various meanings of puncture as a clinical phenomenon are considered with regard to language, loss of an ability to express oneself, and the importance of images for regaining what might be regarded as a proto-form of alpha function as well as mending a torn skin ego. (Contains 1 note.) |
| Abstractor: | As Provided |
| Number of References: | 24 |
| Entry Date: | 2012 |
| Accession Number: | EJ957954 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwG-1ZzxbZVz1wQh1tHurE_tAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDGqY_oYnXwIEYtH7EAIBEICBmuM8xWPh5smeot4GVOLTgoM_B-mcMiSVf3RJr4BRSkZWLfzQRVbvF6D4pPDmGocPAM2fGV6BHnmE5AhZ1e6W4Ae99jKPt3QTu39KY_PNoQ3tGI-634lebQEwOtgKGIEms436qL3cWoeUmzUfIC7oW0KCNs9u1_sW01x3es0fUXd0e-IIa6bveTCeDQ_4ov9jTLGzZK4Fa5R2uW0= Text: Availability: 1 Value: <anid>AN0072411908;5bk01apr.12;2019Feb12.17:25;v2.2.500</anid> <title id="AN0072411908-1">Lost for words: difficulty expressing feelings in work with three adolescent boys. </title> <p>Case material of three adolescent boys is considered with regard to thematic similarity around acts of puncture. Their non-verbal communication is seen as a symptomatic acting out of an internal loss of containment. This resulted in psychotic disorganisation in which aspects of language appeared selectively impaired. Each boy struggled to express emotions and feelings, and was at a loss for words in attempting to describe how he felt. Anzieu's concept of the containing function of the skin ego is examined, as this is a useful idea for thinking about puncture of an internal shell, and what happens when it is not able to withstand disturbing internal forces. Bion's theory of alpha function is also explored to understand further a breakdown in emotional communication. Disruption of alpha function can result in bizarre images. In each case, disturbing imagery was a feature of therapeutic breakthrough, which followed incidents of puncture in the outer world. Various meanings of puncture as a clinical phenomenon are considered with regard to language, loss of an ability to express oneself, and the importance of images for regaining what might be regarded as a proto-form of alpha function as well as mending a torn skin ego.</p> <p>Keywords: Adolescent male development; alpha function; Anzieu; Bion; cutting; language problems; psychosis; skin ego; substance abuse</p> <hd id="AN0072411908-2">Introduction</hd> <p>This article summarises clinical findings from the cases of three adolescent boys, each of whom suffered from an inability to communicate deep states of alienation and depression. Furthermore, there was an urgent need to puncture some aspect of both inner and outer reality, breaking an important and vital boundary. Questions arose about their capacity to verbalise, as well as difficulties in relating to their internal experiences. Communication appeared especially disturbed around emotional content. Damage to or loss of alpha function, as conceived by Bion ([<reflink idref="bib9" id="ref1">9</reflink>]), helps us as psychotherapists to account for an inability to access, metabolise and ultimately express painful states of being. Without alpha function, meaningful thinking and communicating can both become impossible, and this deficit creates profound disorganisation.</p> <p>Although the psychological background for each instance of puncture differs in the following three cases, it is interesting to consider this phenomenon in relationship to a loss of language. Puncture can be associated with acting out, with non-verbally communicating pain that is not yet ready to be spoken about, and with giving expression to a broken self-image. A common feature lies in the action of breaking, and this perhaps describes how whatever minimal sense of containment there is gets shattered. A simultaneous casualty appears to be expressive language. The word 'puncture' derives from the same Latin root as the English word 'punctuate': <emph>pungere</emph>, meaning 'to prick' (<emph>Oxford English Dictionary</emph>, 2011). While this is just an etymological connection, I would suggest that these boys needed to internalise a psychological editor (i.e. to contain, repair alpha function and to dream) that would help to express (cf. punctuate) painful experiences.</p> <p>In adolescence, there typically occur breakdowns of varying degrees in communication with adults, who are regarded by the adolescent as out-of-touch, authoritarian, intrusive, oppressive and so on – this list could grow rather long. In analytical treatment, this appears as a mixture of defensive retreat during times of silence or one-word answers to questions, and of a seeming inability to say more, which may reflect turmoil over struggling to separate while still depending on others. Language in adolescence can become more conflictual than in latency or puberty, because it reveals the workings of a mind that is not entirely sure how revealed it wants to be. This is especially so given the inner pressures of developing sexuality, which strongly reactivates Oedipal themes. In some sense, why would any adolescent want to share details about this process except perhaps with a few trusted peers?</p> <p>A competing adolescent need that brackets this question is a desire to be seen. Looking inside oneself is a stepping-stone to forming an identity and to creating a capacity to relate to others whom one loves, hates or aspires to know better. During this tumultuous period of life, language operates increasingly as an expression of self, although what is proclaimed one moment might be hidden or recanted in the next. The evolving problems of adolescent communication are underscored by the endless stories about how the Internet is now used for cyber-bullying, sexual exploitation, pornography and violent gaming in virtual reality. These represent new venues for communicating, still with words, but without face-to-face contact. Adolescents have fully appropriated the Internet in ways both innocent and sinister, and demonstrate to us its unappealing aspects.</p> <p>Words can be used cruelly and viciously, but their disappearance is even more troublesome. An adolescent can hide or be unseen while significant danger unfolds, and actual risk to his or her wellbeing increases. When acting out, an adolescent often verbalises little or nothing. During latency, this capacity to verbalise, along with repression, helps internally to stabilise a developing child to support growth in social relations and academic learning. But with the onset of adolescence, a storm begins that often derails communicating, and the urge to act can seem like a better alternative to telling anyone about what is happening inside. How many times have we heard a parent of an adolescent say to us in our office, "I just don't understand him any more"? Or, more aptly, "She never talks to me." It is as if the adolescent becomes cryptic, a riddle unto herself and others. This is a phase of adolescent development that Winnicott (1963/1984) describes as the doldrums, and one that he believes is survived by the passing of time perhaps more than anything else.</p> <p>Bion's ideas about containment, and their elaboration by Meltzer ([<reflink idref="bib17" id="ref2">17</reflink>]), Alvarez ([<reflink idref="bib1" id="ref3">1</reflink>], [<reflink idref="bib2" id="ref4">2</reflink>]), Ferro ([<reflink idref="bib12" id="ref5">12</reflink>], [<reflink idref="bib13" id="ref6">13</reflink>]), Grotstein ([<reflink idref="bib14" id="ref7">14</reflink>]), Mitrani ([<reflink idref="bib18" id="ref8">18</reflink>]), Ogden ([<reflink idref="bib19" id="ref9">19</reflink>]) and others, have helped me to understand what additionally – besides time – allows for adolescent growth and maturation. The right balance of internal and external containment underpins the development of a self with a future, with relationships, and with dreams and aspirations. Given this task, we might wonder what psychological forces disrupt the internal containment needed for development to move forward? A big question indeed, and certainly external trauma, deprivation and family instability all play pivotal and decisive roles. Is there, however, an internal component that undermines alpha function, destroying language and expression that comes from a darker layer of the psyche?</p> <p>Adolescent development could be undone by what appears to be a dark, uncontainable force from deep within the personality. From a Kleinian perspective, an adolescent in this state might be considered as using manic defences, losing his or her standing in the healthier part of the personality, and becoming immersed in omnipotent, negative fantasy. This psychological decline would refer to what Meltzer ([<reflink idref="bib16" id="ref10">16</reflink>]) and Anderson ([<reflink idref="bib3" id="ref11">3</reflink>]) have described as being in the grip of the destructive part of the personality, which can frighteningly overtake the developing mind and body of the adolescent, leading to self-destructive behaviours.</p> <p>The following case examples of three adolescent boys illustrate the internal disarray when this occurs. This can be understood to be a result of hijacking alpha function in a developing mind when internal containment is lost. In the aftermath, each boy is left expressionless and unable to communicate. To cope, he searches for something to break, because breaking provides a form of temporary relief – the symptom conveying a misguided attempt to cure psychological distress. Typically, this breaking can be a kind of puncture. However, the relief gained is ultimately unsatisfactory. The danger is that a vicious cycle is unleashed, wherein further relief is sought through more puncturing. The mind becomes psychotically disorganised as a result, and the boy becomes at risk of self-destruction.</p> <hd id="AN0072411908-3">Case example 1: A punctured condom and psychosis</hd> <p>Edward came to me at age 15 upon his own request. His mother had phoned me in an urgent state and said, "He needs to see you today if possible. He won't tell me why, but I know something is seriously wrong." I agreed to see Edward later that day. His mother told me a few facts about their family and I offered to meet her and Edward's father the following day. Edward lived with them and his younger sister, who was 10 years old at that time. His father worked in construction and his mother in an administrative position.</p> <p>Edward presented in a very troubled and disturbed way. He was mumbling to himself, incoherent, and his eyes were darting to and fro. I feared he was overtly psychotic, and asked him if he were hearing voices. He said, "Yes", and I asked if he might tell me what they were telling him. He answered, "They say, 'you're bad, you're evil, you're disgusting'." He appeared agitated and was bouncing on the couch. I said that sounded painful, and that I imagined he'd be feeling awful hearing voices condemn him like that. He relaxed somewhat, and replied, "You got that right." In response to other questions, however, Edward just mumbled, "I can't say. I just can't say."</p> <p>I noticed that Edward kept touching the crotch area of his pants. I thought to enquire about it, but as he was still considerably distressed, I opted to wait a little while. He explained some paranoid ideas about his school and society. Hearing him ramble, I began to feel slightly off balance, as though I were disoriented and looking for a way to steady myself. I found that when I focused on Edward's hands, my feeling of disorientation eased. I wondered what story his hands might be telling in their frenetic and compulsive touching of his crotch.</p> <p>Edward continued on a rant about consumerism and materialism, both of which he said were controlled by our government. I tried to follow his train of thought, but again felt that this was pulling me away from something more central. He wished, "that life could be harmonious like on Star Trek". He believed his school principal was "racist" and "homophobic". I asked why, curious since this remark about homophobia brought sexuality into our discussion. Edward responded that the principal "singles out Hispanics" for punishment. I enquired about the homophobia, and he added that the principal had refused to allow the publication of a school picture for 'The Best Couple That Never Was', which included Edward and a male friend. He told me he was not gay, but he was "sick and tired of how bad gays are treated". As I considered this, I observed that the dance of his hands persisted, and wondered privately if there might have been a sexual experience that Edward felt guilty about – now badly treating himself with hallucinated recriminations.</p> <p>We spoke about his drug use, which was alarming, since it included hallucinogens. This information made me question if he might be in a drug-induced state, although I observed that was not the case since he did not show any other cognitive or behavioural signs of intoxication. For example, the movement of his hands was not sloppy and uncontrolled; on the contrary, it conveyed a peculiar sense of intention. I gently pressed about recent drug consumption, and he assured me that this use had been confined to marijuana two days before. He denied ever having a negative experience that he would attribute to using recreational drugs. This entire time, his hands continued their nervous dance around and near the crotch of his pants. He pulled and tugged at the cloth, and sometimes reached his whole hand under his genital area as if re-arranging a source of discomfort.</p> <p>I realised how helpful it was to me to focus on his hands, and I even had a concrete idea that perhaps Edward's underwear was too tight. But, I also thought there was more to it. I ventured to him that I was noticing his hands, and that I had to think that they were trying to draw my attention to his body. Was there something he might want to tell me about that? He blushed a bit and nodded yes. I said that he hadn't talked with me yet about sex, and I wondered if this topic were on his mind and causing him concern.</p> <p>At this point, Edward dropped his head into his hands, which were now propped on his knees. He began to sob and ran his hands roughly through his hair as if he might pull it out. He muttered softly about not knowing what to say. I sat with him for several minutes while he cried. The hands were now devoted to his head, rubbing his eyes, pressing his forehead, and twirling his longish hair. His hands seemed to confirm a shift away from compulsively touching his genitals and into his head and mind. I said that I thought there might be a story about sex he was waiting to tell someone. He looked at me with swollen eyes and said, "I don't know how you know that, but that's right."</p> <p>Edward then told me a complicated story about his first sexual encounter, which had occurred two months before with an 18-year-old girl. He explained over the following sessions that as it had been "my first time, I was kind of clumsy. I didn't know how to use a condom." He tore two condoms while trying to put them on, and eventually his partner helped him with the third one. However, right before he ejaculated, this condom too broke, although it was too late for him to do anything about it. The girl became pregnant from this punctured condom incident. Throughout this ongoing discussion, there were countless interruptions, when Edward would sit silently, and sometimes state, "I can't say more." His hands no longer moved frenetically, and his mind would stall at these moments. I was aware of how alone he felt even with me, and I commented that he appeared unsure how much to trust me.</p> <p>He slowly told me his story. A few weeks before coming to see me, Edward learned about the pregnancy, which they decided to keep secret. Since the girl preferred an abortion, they went to a clinic together, where they found out how much the procedure would cost. They both raided their meagre savings, and sold personal items to other teenagers, in order to collect the necessary sum. Edward went with her on the day of the procedure. Shortly after this, he reported, "My mind went crazy. The voices came to me, and I got fucking scared I'd never be the same."</p> <p>As I summarise Edward's story, I realise that it makes more sense in summary than in his original telling. Within the latter, there were fits of stopping and starting, interruptions with bizarre paranoid ideas, and feelings of agitation and profound sadness. I continued to worry about his sanity and the reach of his psychosis. Mostly, I was struck by his guilt and a gloomy heaviness that he brought into the room with him. I thought that he was punishing himself for the punctured condom, and I said that he seemed to feel this was completely his fault. He agreed, and revealed that he believed his penis was "too pointy," adding "Maybe that's what happens when you're circumcised" (which led him to paranoid thoughts about why circumcision is widespread in the United States). He said that his penis "has tiny, invisible prickers on it". He added, "That's what broke the condom." He feared he had also injured the girl, and somehow mutilated her insides with this sharp penis.</p> <p>Edward recovered from the acute phase of his psychosis. He did not require any pharmacotherapy, since his psychotic symptoms gradually diminished over the course of several months of psychotherapy with me. He remained a troubled adolescent boy, but he was able to articulate aspects of what had terrified him. He was haunted by an image of the foetus. He described it as "a mutant, damaged beyond recognition, missing brain cells and with an extra limb. It'd be a fucking mess." This image might also apply to Edward's mind when he first came to see me: a demonic force had taken over and disrupted his ability to contain within himself a storm of primitive sexual forces following the episode of puncturing the condom. Whatever limited capacity he had for alpha function was likewise punctured. Edward's 'penis with prickers' was a source of destruction; it not only caused the condom to break, but also impregnated the girl with "a mutant". This penile weapon left Edward with "a fucking mess", evocative of his mind represented by a mutant foetus that eventually had to be aborted.</p> <hd id="AN0072411908-4">Case example 2: Punctured skin and perversion</hd> <p>Anthony was 21 years old, though still very much a boyish adolescent, when we met. He had just finished college and was working full-time. He was a wiry, jumpy fellow who did not seem at all comfortable in his skin. He had long struggled with psychological difficulties that included serious depression with psychotic features and he had been cutting himself since age 12. He grew up in a small town with his mother, and sister who had severe cerebral palsy and was quite disabled. His father abandoned the family when Anthony was five, soon after his sister's birth. His father then led a transient lifestyle, living out of a van that he drove up and down the West coast. Anthony later told me, "I think my father might have Asperger's." He rarely saw his father, and at the start of treatment, had not seen him in over three years.</p> <p>Anthony spoke about the onset of cutting at age 12 as stemming from being bullied and teased by other children: "I was a total wus, a wimp, too timid to stand up for myself. I'd never let my son behave the way I did. No spine." He thought, however, that the cutting proved that he was secretly "strong – that I could stand the pain". Yet disturbingly, he also said, "It was also to let the evil out of me." Anthony shared that he believed he was "possessed" by "evil energy," and that bleeding was one method to release this. In other words, his puncturing his skin was a mistaken attempt at self-healing.</p> <p>He described this as follows: "When I'm bleeding, sometimes I think it lets the evil out of me. Each of the first drops looks like an evil blackness because when you first bleed, the blood is darker. Only when it absorbs more oxygen does it get redder. Those first drops are the beginning of an evil stream. Because I feel I'm so full of evil." When he'd talk this way, I often felt jarred and incredulous, because it was strikingly at odds with his appearance: angelic, timid and immature. Listening to him, I felt my skin crawling. He could sound both creepy and sinister. In terms of projective identification, I thought my skin crawling gave me a feeling of why he cut. This experience was as if I were being scared by a clever monster in disguise with the aim of leaving me to feel helpless and desperate for release. This monster, I came to think, was part of what Anthony felt helpless against.</p> <p>During an early session, I talked at length with Anthony about his cutting. He relished telling me about it, and when I commented on his excitement, he blushed. I mentioned that possibly there was something about the evil that felt like a turn on, and he agreed, "It makes me feel powerful. It's kind of exciting." As I heard this, I thought that Anthony's cutting was a source of perverse sexual satisfaction. I enquired, "Has anyone ever just asked you to stop doing it?" He looked both amused and surprised, and answered, "No. Actually no." I added, "I think I'd like for you to stop it." He asked if I intended to medicate him if he didn't, and I thought his question conveyed that he saw me as someone potentially retaliating against him. I said no, but that I would like the chance to take care of him in a different way. This involved our trying to understand together how his mind worked, since I believed there was another pain that I needed to hear about instead of only what came from his cutting.</p> <p>Anthony cautioned me, "I'll think it over." In the next session, he brought in several drawings that he'd made of himself, self-portraits, that depicted him as a gargoyle. These were drawn with excellent skill, detailed shading and accentuated three-dimensional perspective. There was a series of five of them, beginning with one of Anthony as a baby gargoyle in an egg. This baby creature's most prominent feature was its large claws. The 'adult' gargoyles were likewise characterised by long, powerful claws. Their bodies were sinewy and naked except for a shaded loincloth. The heads were bald, the noses protruded, and the mouths were overly small and filled with pointed, feline teeth.</p> <p>As we looked at his drawings, I asked Anthony how he felt showing them to me. He said that he had shown them to a previous therapist, who seemed frightened by them, and told him he was psychotic. His opinion of her was, "She over-reacted." I wondered if he might have a similar worry about me, and he said, "Well, what do you think?" I answered that I thought these drawings contained many possible meanings about how he saw himself. He rolled his eyes, and warned me, "They're just drawings." I said that was true, but these drawings seemed to be about someone who might have felt lonely and outcast. He argued, "You're reading too much into them." His repeated negation of my observations felt to me as though he was cutting off our interaction from going anywhere more meaningful, in other words using his imaginary claws to tear away at our relating.</p> <p>I replied that perhaps he thought I was now over-reacting like the other therapist, when I hoped instead to understand his feelings. I continued that maybe these were what felt like reactions that were too much for him. He paused, then nodded. "That's a possibility. I can't even describe my feelings." When it came to questions about his feelings, Anthony would usually stare blankly ahead, speechless. More than once, he said his feelings were, "insects that I can't identify".</p> <p>At the end of this session, Anthony wanted me to keep his drawings. I made what might have been a technical error, because I suggested he take them and bring them back next time. This decision bothered me as I reflected on how many times younger children wanted me to keep their drawings in the office, and I agreed as a way to hold and to contain something of importance. Why didn't I do the same for Anthony? I thought at the time that I was exploring how he handled this limit, similar to my request that he not cut anymore. Now, I think that I enacted a countertransference anxiety around how close I wanted to let him get to me. As I later learned, Anthony's perverse behaviours extended quite far, and possibly intuiting some of this, I chose to create some distance by giving him back the drawings.</p> <p>After this session, we occasionally discussed the gargoyles, although thematically we stuck with the direct ways in which Anthony felt alienated from others, from me, and from himself. He continued in treatment with me for another three years, and during this time, he never again cut himself. He often referred to the encounter of my asking him not to cut as "meeting Dr No". While this might have aspects of a projective identification of his own negating self, he more than once joked that "Dr No could be N-O, or it could be K-N-O-W." I thought by this he meant that he was beginning to get that I might know when limiting himself was a good choice that provided containment.</p> <p>The images of the gargoyles offered Anthony an opportunity to communicate a profound loneliness and his belief he was an outcast, 'cut' off from others. These self-portrayals released unprocessed aspects of his self (beta elements comprised of raw aggression) that had previously been driving him mad. They constituted a projective identification into our relationship of him as a clawing creature that, he likely fantasised, could rip me to shreds. I felt that I had to find ways for us to feel close to each other. This was a challenge. Anthony's perverse world included a women's underwear fetish that involved stealing underwear and wearing it while he masturbated. He fantasised that the woman would feel humiliated when she discovered what he had done. Additionally, I much later learned that he compulsively viewed child pornography. His sexual interests were directed at adolescent girls, perhaps indicative of the time in his life when his development went seriously awry around his own puberty that included being bullied, feeling weak and the onset of cutting himself.</p> <p>Anthony's gargoyle identity, like Edward's mutant baby, represented his state of mind when he began treatment. Although mathematically brilliant, Anthony had been an under-achiever because his psychosis disrupted his capacity to think for very long. The gargoyle, capable of tearing apart his mind with its claws, made him more stupid than he really was. It shredded not only alpha function, but also any good internal objects that could contain him. Although Anthony obtained short-term relief from his suffering and isolation through self-inflicted puncture, an identification with the destructive side of his personality consumed him. This destroyed his ability to speak about how he felt, let alone to think about feelings.</p> <p>Straker ([<reflink idref="bib21" id="ref12">21</reflink>]), in an article about adolescents who cut, hypothesises that cutting attempts to build self-structure through being one's own mirror, that is by trying to exist outside of intersubjective experience (she refers to this as 'auto-mirroring'). She believes this will fail because such a self is never truly seen by another. Anthony retreated into a perverse world that had many omnipotent, autoerotic qualities that Straker describes. This dynamic changed considerably during his treatment with me, possibly because I saw multiple sides of Anthony's 'evil blackness', which continued to have an effect of unnerving me. Eventually, he was able to limit himself around his perverse sexual tendencies, in large part because of the containment he experienced through our relationship.</p> <hd id="AN0072411908-5">Case example 3: Punctured glass and mania</hd> <p>Douglas was 18 years old when we met. He was sent home from college because he was incapacitated by depression and drug abuse. He came to the college's attention because of the severity of his regression, which had caused him to lock himself in his room for days at a time, not even leaving for basic hygiene. Douglas lived with an older sister and brother, and his two parents, who ran a business in the medical field. Douglas's second and oldest brother had just graduated from college and taken a job in another city. Douglas had an erratic academic history, clearly quite bright but frequently achieving poorly. He reported that when he was in elementary school he often ripped up his homework after completing it, and sometimes hit himself on the face and head. Tall and overweight, Douglas appeared with dark circles under his eyes, and slouched in a chair in my office. He was dressed in loose athletic clothing, and seemed to have recently woken up. He spoke loudly and was generally defensive in a manic way. He told me, "I don't really need to be here. The university is making a big deal about nothing." He tried to impress me with how intelligent he was, and shared with me his excellent scores on college admissions exams. When I asked what he enjoyed learning at school, he replied, "Not much. The professors are fucking idiots, almost all of them. I'm way smarter than practically any of them. They just want you to regurgitate their pet ideas back to them, and I'm not into that bullshit." I thought he was likewise judging me to be another 'fucking idiot'.</p> <p>I asked how it came about that he decided to attend college, and he answered that his parents "would have flipped if I didn't". He said that he'd applied to eight schools and he had not been accepted by any, so that circumstances forced him to attend a less prestigious college for a year before his grades were adequate to transfer. Douglas finished his first term at the new university, but then began "to sleep all the time". I asked him what had happened. He replied, "I don't know. Er, I can't put it into words." I wondered whether he had been depressed to be asleep so much, and he answered, "I don't know. What's depressed?" He looked perplexed.</p> <p>Douglas was often argumentative with me in an imperious manner. I sometimes felt pummelled by him, even beaten and banged around by his barbs, veiled insults and demeaning tone. He tried to provoke me in boastful ways. For example, early on when I commented on his looking uncomfortable during a conversation about depression, he replied condescendingly, "Oh, really? How observant. Did you learn to say things like that to your patients in grad school? I hope it wasn't a complete waste of your parents' money." It became clearer to me that he was subjecting me to how he felt within his family, where he took the brunt of mean jokes, sarcastic commentary and physical blows from his older brothers. Douglas continued to abuse drugs (marijuana, amphetamines, hallucinogens) and alcohol despite my opinion that this was hurting him. He questioned my knowledge and asserted, "I looked it up on the Internet. It's not nearly as harmful as you say. If it was, the whole country would be retarded." He came the session after this exchange with a bandaged hand. He told me he had been in a bar fight, and had broken a window. I thought he wanted me to see him as fearless.</p> <p>Watching him act out in dangerous ways, I got a sick feeling we were headed for calamity. I wondered if this might be how a battered spouse felt, a foreboding tension apparent before an explosion. Then, Douglas came to a session visibly high with dilated pupils, slurred speech and euphoric mood. I said although he might have wanted me to see him like this, there was little way for me to help him when he was high. Angry over what probably seemed like my moralising to him, he missed several of our next sessions. I sent him a short note, which he responded to by calling and saying, "I'll be there this week."</p> <p>When he showed up, he told me that he had lost his job for insubordination. He had publicly cursed at his boss, and was fired on the spot. I asked if he were concerned, and he answered, "Not really. There are plenty of jobs in this city." He derided the boss, "He's a fucking idiot!" I thought he'd acted out his rage at me, though directed at the boss, for my being an idiot when I had recently talked with him about his drug abuse.</p> <p>Two weeks later, a major crisis occurred, confirming my sick premonition. When I went to the waiting area, I was startled. Douglas had two black eyes; his right arm was in a cast; there were several deep scratches on his face, and bruises on his other arm; he limped into my office. He was pale, and sunk heavily onto the couch. He began, "Yeah, I know, I look like crap."</p> <p>Douglas told me that he'd taken hallucinogenic mushrooms with a friend, and that he had lost control, stripped and ran almost naked through one of the busiest thoroughfares in the city. He ran down this street barefoot and believed at the time he was being pursued by "huge black bats, killer bats right out of a sci-fi movie". He began smashing car windows with his bare hands, knocked off side mirrors on some cars, and finally believing that the bats had "morphed into zombies," he used his right hand to punch through the windshield of a Jaguar because he thought the zombies were taking it to chase him. Police arrived and subdued him. Because he needed medical attention, they took him to a hospital emergency room. He told me the whole event "was hilarious – one of your patients running down [the street's name] almost naked. How often do you hear that?" I commented that he wanted to shock me, and it worked, but I was also very worried about him. I realised that I felt angry both at my inability to get through to him and at taking something of a beating from him. Although he'd banged me around during our sessions, now he was the one who got banged up outside.</p> <p>I reflected to him that while he was trying to make light of a serious situation, I could see many ways he was visibly hurt. I imagined it to be painful. I wondered if we could think together about my helping him so he wouldn't hurt himself like this again. He answered, "It's just a fucking joke." I thought he was waiting to see if I'd give up on him. I said that his life was no joke to me. He paused, and grew sombre, "Oh." After a long silence, Douglas sighed and asked, "So what are we going to do?" I replied that he'd just said 'we'. He became suddenly anxious, fidgeting on the couch, and stuttered, "Er, I ... I ... I guess that's, that's, that's what I said. Yeah, yeah. You and, and, and me." This moment when Douglas stuttered inarticulately is probably when the therapy was able to take hold and move in a more meaningful direction.</p> <p>After this, he became more openly depressed, sleeping a lot, crying for reasons he could not understand, and stating, "I think this must be what sad is." What particularly saddened him were the sadomasochistic relationships within his family. He described the relentless competitiveness and aggression that characterised how they interacted with each other – banging each other around with put-downs, insults and cruel jokes. Moreover, he related that his older sister had sexually abused him when he was quite young, and no one had ever known about this. Perhaps at that younger age when he had hit himself on the face and head, he was attempting to communicate to others just how awfully wrong the situation was at home. In this family, words counted chiefly as weapons.</p> <p>Not surprisingly, in this environment, Douglas acquired little reliable internal containment. He could not really think (or dream, or use alpha function) because what he knew best was evacuation and discharge of his own impulses externally. It was no wonder he struggled in school despite good intelligence. For him, hitting and breaking were a manic release of his own anger and sexuality. During his openly manic phases, he referred to sex as "banging girls". There was no way that he yet knew how to be close in a way that was softer and affectionate. He did know about shattering things. His frequent breaking, ripping and hitting expressed something internal that was constantly breaking too – a mind barely held together. Like Anthony, Douglas used his body to represent how problematic and extreme his pain was, and how damaged he felt himself to be. The images of killer bats and zombies depicted internal persecutory objects that made him crazy (batty) and depressed (dead like zombies). Despite these considerable challenges, he remained in treatment for another two years and was able to stop his use of drugs and alcohol.</p> <p>During the immediate aftermath of the acute crisis, I considered whether Douglas might have required a stay on a psychiatric unit. While he was at the hospital's emergency department, he did not speak with any psychiatric staff who might have assessed this need at the moment it presented. In California, there is a procedure for instituting a 72-hour involuntary hold within a hospital when someone is a danger to himself or others. However, in recent years, this occurs less frequently than one might surmise, and at-risk teenagers are often discharged once medical clearance is given. Douglas's situation was additionally complicated by the legal fact that as an 18-year-old, he had the privacy right to deny any of his doctors from communicating with one another or with his parents. Only later in his treatment would he permit me to speak with his parents.</p> <hd id="AN0072411908-6">Lost ability to name and express feelings</hd> <p>At a special school where I formerly worked, the children, mostly boys, had significant social and medical problems in their backgrounds. When I began my work there, I often sat and observed, and found myself thinking that many of these boys reminded me of nursing home patients. They had trouble speaking, strange gaits and they were socially awkward, clumsy, disoriented and forgetful. It was as if these children were stroke victims, especially in how they moved so oddly. I mentioned this observation after a lecture that Anne Alvarez ([<reflink idref="bib2" id="ref13">2</reflink>]) gave in San Francisco. She found the comparison interesting, since her lecture had been about how, in children with autism or psychosis, problems in walking often mirrored problems in thinking. The boys at this school were understandably at a loss for words because of experiences of deprivation, poverty, violence and other trauma that impinged upon their brain's hardware. Consistently two-thirds of these boys required intensive speech therapy to address their language disorders (Tyminski and Goel, 2000).</p> <p>Loss of speech can be a feature of many psychological conditions, for example an obsessive avoidance of particular words, truncated word usage found in certain psychotic and autistic states, and elective mutism. Certainly, in adolescence, communication can become sparse. An intense need for privacy, keeping secrets and a move to separate from family: these all have an effect on how much is said, and to whom it is related. The adult world is particularly suspect and regarded as a likely source of intrusion and misunderstanding. The phenomenon of brooding in adolescence is characterised by withdrawal, moodiness and few words. Language is imbued with qualities of unwanted exposure and anxiety since it can become a possible avenue for uninvited infiltration into an adolescent's psyche.</p> <p>The psychological problems described in the cases of Edward, Anthony and Douglas arose in different circumstances, and yet they shared in common a feature of being at a loss for certain words to describe emotions and feelings. Each of them struggled to convey to others what happened inside emotionally. Edward's initial incoherence ("I can't say") indicates an extreme end of this spectrum. Anthony's seemingly articulate and intelligent nature shows another variation of difficulty in communicating, when, for example, he referred to his feelings as "insects" that were "alien" to him. Similarly, Douglas was capable of fluent, abstract conversation that he used to attack others and defend himself, although he experienced a peculiar loss of words ("What's depressed?") when it came to describing how he felt. In these three cases, the range of not communicating emotionally stretched from incoherence (Edward), to dissociation (Anthony), to confusion about naming (Douglas).</p> <p>Some of the clinical observations could be classified as defensive: the boy does not want to let someone inside, or he does not want to look inside himself. Aspects of language are avoided to protect an inner fragility. But I think their loss of feeling words extended beyond defensive purposes. In their respective states of breakdown, each showed how a destructive part of the personality undermined a capacity to communicate. The disturbing images (mutant baby, gargoyle, giant bats transformed into dead zombies) afforded glimpses of how the destructive part produced internal disarray.</p> <p>In thinking of these cases, one has to bear in mind that a loss of internal containment goes hand in hand with enabling the destructive part of the personality to become ascendant. While I have not discussed each boy's family history in detail, there was a prevalent failure to internalise useful, good enough parental objects. The absence of these, in a process that has been described by Bion ([<reflink idref="bib9" id="ref14">9</reflink>]), Odgen (2009), Ferro ([<reflink idref="bib12" id="ref15">12</reflink>], [<reflink idref="bib13" id="ref16">13</reflink>]) and others, creates a lack of internal containment that leads to severely disturbed states of mind (see also Bion, [<reflink idref="bib8" id="ref17">8</reflink>]). Edward's parents grew marijuana at home, and Edward described their house as being in "a haze" (of smoke) so dire that he feared for his health. His father was almost always high. Anthony's father was for him "a sad case", and his mother diverted her attention from him to his disabled sister, whose care exhausted her. Douglas's parents created a family atmosphere that was far removed from a nurturing home. Each case demonstrates the profound disturbance emerging when parental objects are missing, unavailable or attacking. What becomes internalised is itself dangerous, and perhaps defies accurate naming and describing to a degree.</p> <hd id="AN0072411908-7">Puncture and the bizarre images</hd> <p>Puncture is not necessarily related in a causal way with loss of words in these boys. In each of the clinical examples, puncture involved a broken surface and a part of the boy's body, i.e. windows and hands; condom and penis; and blade and skin. A boy's body in adolescence is charged with sexual energy and many conflicts around what to do with it. Masturbation as an outlet does not involve a conscious act of penetration, and in at least two of the cases (Anthony and Edward), there were reports of compulsive masturbation. Masturbating was experienced as comparatively safe, whereas penetration seemed to signify an elusive, dangerous masculinity. Edward was guilt-ridden with an idea that his "prickered penis" broke the condom and created a mutant baby; the act of penetration became traumatising for him. Anthony cut in a perverse form of self-penetration to imagine that he was no 'wimp', but instead strong and potent. This gave him an imagined Oedipal advantage of trouncing his own weak father, who had produced a 'freakish' sister for Anthony.</p> <p>In these three cases, puncture occurred as a by-product of a deeper phenomenon that could be considered fractured internal containment. As such, puncture is a symptomatic expression for a rupture of the mind that destabilises and enables destructive forces in the boy's personality to gain an upper hand in dominating his psyche. Loss of emotional communication is but one possible consequence of this process. When this happens, however, it renders the boy incapable of describing and speaking about what it feels like inside himself. Problems then arise in identifying feelings; in perceiving them; and in containing them.</p> <p>For these boys, bizarre images expressed aspects of the pain associated with puncture. Bovensiepen ([<reflink idref="bib11" id="ref18">11</reflink>]), a Jungian analyst, articulates an idea that such imagery can point toward the emergence of symbolisation for harsh, even traumatic parts of experience. He too uses Bion's concept of turning beta into alpha elements for describing how some of this process unfolds. His case example, based on medical trauma that a nine-year-old boy had suffered early in life, shows how violent and destructive images are created as part of a comic book game played between the analyst and his young patient. Such images have utility, and could be conceived as indicating a dawn, or even a restoration, of alpha function, to convert beta elements into metabolised pieces of psychic experience.</p> <p>In my case examples, alpha function may have existed in a proto-form, which is eidetic, bizarre and disconnected from linguistic expression. If so, then it is critical to take up images verbally for further transformation to proceed. As we discussed them, it was important to get at the bodily pain that the puncture caused. The images offered an entry into this material, and the focus quickly shifted to body-based anxieties and fears. Mishaps of puncture seem to encompass a view of body image that can be destructive, mutilated or misshapen. For example, Douglas, after he settled into working with me instead of against me, announced that he thought he had body dysmorphic disorder, and soon began a course to become a physical trainer at a gym.</p> <p>In trying to understand the psychological underpinnings of puncture, I was drawn to the work of Anzieu ([<reflink idref="bib4" id="ref19">4</reflink>], [<reflink idref="bib5" id="ref20">5</reflink>], [<reflink idref="bib6" id="ref21">6</reflink>]). He writes about the skin ego and its multiple organising functions for the psyche. Among these, he finds that the 'containing function' corresponds to the skin that covers 'the entire surface of the body and into which all the external sense organs are inserted' (Anzieu, [<reflink idref="bib4" id="ref22">4</reflink>]: 873/1989: 101). The skin ego as container stems from maternal 'handling' that encircles the infant. Physically as well as psychologically, the skin becomes a sac. The mother's care, touch and attention all serve to create through the experience of the skin a container for the infant's distress, sensations, affects and projective identifications. Anzieu's work builds upon Bick's ([<reflink idref="bib7" id="ref23">7</reflink>]) groundbreaking contribution about the skin in early object relations.</p> <p>Anzieu uses the metaphor of a kernel and shell: the kernel representing instinctual impulses, and the shell a container of the skin ego. He describes what happens when there is a failure of this:</p> <p>An instinctual excitation that is diffuse, constant, scattered, non-localizable, non-identifiable, unquenchable, results when the psychical topography consists of a kernel without a shell; the individual seeks a substitute in physical pain or psychical anxiety: he wraps himself in suffering.(Anzieu, [<reflink idref="bib4" id="ref24">4</reflink>]: 873/1989:102)</p> <p>We might think of the three cases I have described as demonstrating a form of this failure of containing, which results in a break (internal puncture) of the skin ego, and the substitution with an envelope of pain and suffering. For Anthony and Douglas, the latter found expression in bodily harm; for Edward, it took the form of hallucinations derived from internal persecutory attacks. Were the disturbing images dream-like attempts by these boys to begin a repair of their skin ego to re-establish its lost containing function?</p> <p>Edward broke condoms in trying to achieve a masculine right of passage in his sexual development. The terrorising image that his mind produced was that of a 'mutant foetus with an extra limb'. Interestingly, while his communicating this helped bring him out of a psychotic state, it also reflected an uncertain and fragile outcome, since the mutant, aborted foetus could also be understood as Edward's fear about his treatment with me: he might not recover.</p> <p>Anthony's long history of cutting had maintained a kind of perverse pseudo-equilibrium, permitting some compensation for feelings of helplessness through an omnipotent idea of strength that he imagined by puncturing his own skin. The drawings of himself as a gargoyle opened the door for something new to come in, but only after I suggested a limit on the cutting. I think he wanted to see if I'd be either excited or frightened by the gargoyle drawings. He may have wondered: would I keep them myself to become perversely excited, or cut them up in disgust? Perhaps my limit of giving him back the drawings did invoke a useful boundary of wait-and-see, i.e. my not getting swept up into perverse content. Anthony felt contained by my care, and he internalised this, which in turn enabled him to entrust me with even more disturbing aspects of who he was.</p> <p>Douglas was flummoxed when asked about his depression, "What's depressed?" Only when telling me about being chased by "huge killer bats" that "morphed into zombies", did he and I break through to a serious conversation about our working together. His drug-induced images had the scent of death about them. Months later, Douglas faced a reality that sobers most if not all of us: we can – and will – die. For him, death as a facet of human experience brought home a real and frightening recognition that his omnipotent fantasies were ways to avoid the limits of his own life. He often cried when discussing this subject, for example, his own brush with a deadly situation ("I might have died that day.") or when he described a young cousin who died and "got a raw deal". The images of the killer bats and zombies helped in a moment of crisis to bring out deeply disturbed parts of himself. Sensing that these would not be rejected, he opened to the idea of our working together.</p> <p>The images facilitated a dialogue and offered a context for a breakthrough. They helped to express aspects of what had turned into a dangerous external puncture. When these images were communicated within the therapy, important emotions followed. They framed an experience of puncture and tried to express feelings of terror, agony and alienation. The bizarre images thus contributed to repairing a cracked shell (or broken skin ego along the lines articulated by Anzieu, [<reflink idref="bib5" id="ref25">5</reflink>]).</p> <hd id="AN0072411908-8">Conclusion</hd> <p>In the absence of adequate external and internal containment, the destructive part of the personality can undermine, break or destroy a rudimentary capacity for alpha function. This can arise as a consequence of an internal puncture that rips apart the skin ego and with it, the mind. The appearance of a terrifying image related to this event might be conceptualised as something like an attempted eidetic repair of alpha function so that verbal expression can subsequently occur. Anzieu ([<reflink idref="bib6" id="ref26">6</reflink>]) sees dreaming and the film of the dream as the way the skin ego is repaired.[<reflink idref="bib1" id="ref27">1</reflink>]</p> <p>Bion writes, 'Reversal of alpha function means the dispersal of the contact-barrier and is quite compatible with the establishment of objects with the characteristics I once ascribed to bizarre objects' (Bion [<reflink idref="bib9" id="ref28">9</reflink>]: 25). Might not an attempt to restore the contact-barrier in an already fragmented psyche also create images that indicate efforts to re-establish alpha function? Such images might indicate reversal (going in the direction of fragmentation) or alternatively, hope to re-gain what has been lost (overcoming the destructive part of the mind). The latter approximates Anzieu's concept of repairing the 'shell' and the containing function of the skin ego, as a protection from internal chaos (Anzieu, [<reflink idref="bib5" id="ref29">5</reflink>]: 101–2).</p> <p>Loss of words that signify and express emotional meaning suggests something about the specific toll taken by internal puncture of the skin ego or shell. Bion states, 'I think that what the patient <emph>feels</emph> is the nearest thing to a fact – as I ordinarily understand it – that he is ever likely to experience' (emphasis added, Bion, [<reflink idref="bib10" id="ref30">10</reflink>]: 7). When alpha function is disrupted, language too is at risk: with a loss of emotional expressivity, language becomes broken, shattered, and characterised by gaps in fluency that do not easily mend. A loss of communicative ability can bring with it intense bodily preoccupations that are self-destructive. In such a state, the action of a real puncture appears as a pathological sign of internal and relational brokenness.</p> <p>How might we conceptualise the metaphorical dimensions of puncture? To puncture is an act of breaking through, and one that ruptures a division of separate spaces. Through this perforation, entry is gained to another closed and often protected space. From a sexual standpoint, it is akin to penetration. Edward's situation most clearly resembles this aspect of puncture with his tale of the broken condom. One could also see in this case some of Edward's Oedipal dilemma of identifying with a weakened father who enshrouds himself in a cloud of marijuana.</p> <p>Literally, puncture connotes piercing, crossing and violation. We can see in Anthony's perverse compulsion to cut how this violation served both to punish himself for being weak and to feed omnipotence about an imagined ability to withstand pain. Symbolically, a puncture that breaks through can also mean crossing into new territory, and in that manner, puncture can also allude to a later adolescent process of moving into adulthood. This meaning has more of an initiatory context that represents crossing a threshold, and in many ways, this reflects the experience of Douglas, who failed at his attempt to 'launch' into more independent living and had to return home.</p> <p>In ordinary everyday use of language, we speak of getting to the point, cutting someone off, sharpening an argument, trimming our expectations, carving out an exception, breaking through the nonsense, and puncturing someone's dreams or pride. Linguistically, puncture seems to represent clarity as well as a discriminating mind that can categorise and create order based on observable differences. Along these lines, puncture could be viewed as an aspect of thinking itself, one that moves right into the core of a subject, separates overlapping and indistinguishable parts, and thereby makes these available for reorganisation.</p> <p>The German philosopher and essayist Johann Gotttfried Herder, who lived and worked mainly in the later eighteenth century, wrote a treatise on human language, specifically about the origins (German: Ursprung) of language (Herder, 1966/2001). He proposes that language emerges only when human nature has a capacity for containing the totality of its experience. He defines this totality as referring to a unity of feeling and thinking, of receiving and doing. Herder argues that an exclusion of one or the other degrades our capacity to communicate through language. He views language above all as naturally incorporating the many paradoxes of human existence (Dasein). When we lose this capacity to express all that our existence encompasses, we lose our humanity. We become alienated.</p> <p>In the cases of Edward, Anthony and Douglas, a frightening loss of language occurred. At the onsets of their treatments, they were not able to communicate how they felt, which emotions stormed inside them, and even how these feelings might be named. They were in states of profound alienation, in which disturbing parts of their existence had been broken off and become largely inaccessible to verbal expression. They were each able to use the containing aspects of a therapeutic relationship to speak about what in them had suffered great pain and brought about an internal puncture. This process helped to address some of their difficulties with a torn skin ego, specifically as it provides a useful internal shell. In this endeavour, it was my hope that they each felt not only more contained, but also less alienated.</p> <p>Finally, it is important to reflect on the assessment of risk when we treat adolescents who show destructive and self-destructive behaviours. When might our ability to offer therapeutic containment be unrealistic, especially in an outpatient setting of private practice? When might we have inadvertently gotten 'in over our heads'? This can be harder to judge than we sometimes know, which is why professional consultation is invaluable. And, who else in our young patient's circle is available to assist us, especially during a crisis? I think I would have been better equipped in Douglas's case if I had been able to agree with him at the beginning of his therapy that we would involve his parents in some way. In contrast, Edward independently requested several family sessions, during which he confronted his father over his marijuana use; addressing this conflict opened a way for Edward to examine his own drug use and to separate somewhat from a father whose weakness in this regard frightened him.</p> <p>Containing risks during what is inevitably a period of development that explores and pushes them – this is a specific therapeutic challenge in treating adolescents. Twoareas for obvious concern include a patient's refusal to allow helpful contact with available resources (something that can usually be navigated while protecting his or her privacy) and a patient's wilful ignorance of the legal and health consequences of very disturbed behaviours (something beyond stubbornness that instead activates identification with destructive parts of the personality). Although Winnicott (1956/1984) saw hope in the antisocial tendency, he also envisioned its containment through 'an ever widening frame' that reached out from mother's body, parental relationship, home, extended family, school, etc. As we think about safeguarding adolescents in our care, we might keep his image of concentric circles in mind, and evaluate where the demarcated lines are weak, and where they are strong.</p> <hd id="AN0072411908-9">Acknowledgement</hd> <p>I would like to express my gratitude to two colleagues who graciously commented on earlier versions of this article: Drs Mary Brady and Hope Selinger.</p> <hd id="AN0072411908-10">Notes</hd> <ref id="AN0072411908-11"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref3" type="bt">1</bibl> <bibtext> 1. Douglas and Edward both reported recurring nightmares, whereas Anthony sometimes told of dream fragments consisting of bizarre, Kafkaesque images and scenes.</bibtext> </blist> </ref> <ref id="AN0072411908-12"> <title> References </title> <blist> <bibtext> Alvarez, A.1992. Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline, Deprived and Abused Children, London and New York: Routledge.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref4" type="bt">2</bibl> <bibtext> Alvarez, A.'A new look at the concept of unconscious phantasy with Bion and child development in mind: links between the dynamic form of unconscious phantasy, and walking and thinking in three child cases'. Paper presented as part of the Child Development Program of the San Francisco Psychoanalytic Institute and Society. April51997, San Francisco, California.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref11" type="bt">3</bibl> <bibtext> Anderson, R.1998. "'Suicidal behaviour and its meaning in adolescence'". In Facing it Out: Clinical Perspectives on Adolescent Disturbance, Edited by: Anderson, R. and Dartington, A.New York: Routledge.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref19" type="bt">4</bibl> <bibtext> Anzieu, D.1984. 'Fonctions du moi-peau'. L'Information Psychiatrique, 60: 869–875.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref20" type="bt">5</bibl> <bibtext> Anzieu, D.1989. Edited by: C, Turner. New Haven, , CT: Yale University Press. The Skin Ego, trans</bibtext> </blist> <blist> <bibl id="bib6" idref="ref21" type="bt">6</bibl> <bibtext> Anzieu, D.1993. "'The film of the dream'". In The Dream Discourse Today, Edited by: Flanders, S.London: Routledge.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref23" type="bt">7</bibl> <bibtext> Bick, E.1968. 'The experience of the skin in early object relations'. International Journal of Psycho-Analysis, 49: 558–566.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref17" type="bt">8</bibl> <bibtext> Bion, W.R.1959. 'Attacks on linking'. International Journal of Psycho-Analysis, 40: 308–315.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref1" type="bt">9</bibl> <bibtext> Bion, W.R.1962. Learning from Experience, Lanham, , MD: Rowman &amp; Littlefield.</bibtext> </blist> <blist> <bibtext> Bion, W.R.2005. The Italian Seminars, London: Karnac.</bibtext> </blist> <blist> <bibtext> Bovensiepen, G.2002. 'Symbolic attitude and reverie: problems of symbolization in children and adolescents'. Journal of Analytical Psychology, 47: 241–257.</bibtext> </blist> <blist> <bibtext> Ferro, A.1999. The Bi-Personal Field: Experiences in Child Analysis, London and New York: Routledge.</bibtext> </blist> <blist> <bibtext> Ferro, A.2009. Mind Works: Technique and Creativity in Psychoanalysis, East Sussex, UK and New York: Routledge.</bibtext> </blist> <blist> <bibtext> Grotstein, J.S.2000. Who is the Dreamer Who Dreams the Dream?, Hillsdale, , NJ: The Analytic Press.</bibtext> </blist> <blist> <bibtext> Herder, J.G.2001. Abhandlung über den Ursprung der Sprache, Stuttgart: Reclam (original work published 1966).</bibtext> </blist> <blist> <bibtext> Meltzer, D.1973. Sexual States of Mind, Perthshire, Scotland: Clunie Press.</bibtext> </blist> <blist> <bibtext> Meltzer, D.1981. 'The Kleinian expansion of Freud's metapsychology'. International Journal of Psycho-Analysis, 62: 177–185.</bibtext> </blist> <blist> <bibtext> Mitrani, J.L.2001. 'Taking the transference: some technical implications in three papers by Bion'. International Journal of Psycho-Analysis, 82: 1085–104</bibtext> </blist> <blist> <bibtext> Ogden, T.H.2009. Rediscovering Psychoanalysis: Thinking and Dreaming, Learning and Forgetting, East Sussex, UK and New York: Routledge.</bibtext> </blist> <blist> <bibtext> Oxford English Dictionary. (2011) Oxford, UK: Oxford University Press</bibtext> </blist> <blist> <bibtext> Straker, G.2006. 'Signing with a scar: understanding self-harm'. Psychoanalytic Dialogues, 16: 93–112.</bibtext> </blist> <blist> <bibtext> Tyminski, R. and Goel, P.2000. 'Outcome-based evaluation of day treatment for children with pervasive developmental disorders'Unpublished manuscript</bibtext> </blist> <blist> <bibtext> Winnicott, D.W.1984. "'The antisocial tendency'". In Deprivation and Delinquency, Edited by: Winnicott, C., Shepherd, R. and Davis, M.London and New York: Tavistock Publications (original work published 1956).</bibtext> </blist> <blist> <bibtext> Winnicott, D.W.1984. "'Struggling through the doldrums'". In Deprivation and Delinquency, Edited by: Winnicott, C., Shepherd, R. and Davis, M.London and New York: Tavistock Publications (original work published 1963).</bibtext> </blist> </ref> <aug> <p>By Robert Tyminski</p> <p>Reported by Author</p> </aug> <nolink nlid="nl1" bibid="bib17" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib12" firstref="ref5"></nolink> <nolink nlid="nl3" bibid="bib13" firstref="ref6"></nolink> <nolink nlid="nl4" bibid="bib14" firstref="ref7"></nolink> <nolink nlid="nl5" bibid="bib18" firstref="ref8"></nolink> <nolink nlid="nl6" bibid="bib19" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib16" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib21" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib11" firstref="ref18"></nolink> <nolink nlid="nl10" bibid="bib10" firstref="ref30"></nolink> |
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| Items | – Name: Title Label: Title Group: Ti Data: Lost for Words: Difficulty Expressing Feelings in Work with Three Adolescent Boys – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Tyminski%2C+Robert%22">Tyminski, Robert</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Journal+of+Child+Psychotherapy%22"><i>Journal of Child Psychotherapy</i></searchLink>. 2012 38(1):32-48. – Name: Avail Label: Availability Group: Avail Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: PhysDesc Label: Physical Description Group: PhysDesc Data: PDF – Name: Pages Label: Page Count Group: Src Data: 17 – Name: DatePubCY Label: Publication Date Group: Date Data: 2012 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Verbal+Communication%22">Verbal Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Nonverbal+Communication%22">Nonverbal Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Concept%22">Self Concept</searchLink><br /><searchLink fieldCode="DE" term="%22Males%22">Males</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Case+Studies%22">Case Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Response%22">Emotional Response</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Impairments%22">Language Impairments</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Psychosis%22">Psychosis</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Abuse%22">Drug Abuse</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1080/0075417X.2011.651842 – Name: ISSN Label: ISSN Group: ISSN Data: 0075-417X – Name: Abstract Label: Abstract Group: Ab Data: Case material of three adolescent boys is considered with regard to thematic similarity around acts of puncture. Their non-verbal communication is seen as a symptomatic acting out of an internal loss of containment. This resulted in psychotic disorganisation in which aspects of language appeared selectively impaired. Each boy struggled to express emotions and feelings, and was at a loss for words in attempting to describe how he felt. Anzieu's concept of the containing function of the skin ego is examined, as this is a useful idea for thinking about puncture of an internal shell, and what happens when it is not able to withstand disturbing internal forces. Bion's theory of alpha function is also explored to understand further a breakdown in emotional communication. Disruption of alpha function can result in bizarre images. In each case, disturbing imagery was a feature of therapeutic breakthrough, which followed incidents of puncture in the outer world. Various meanings of puncture as a clinical phenomenon are considered with regard to language, loss of an ability to express oneself, and the importance of images for regaining what might be regarded as a proto-form of alpha function as well as mending a torn skin ego. (Contains 1 note.) – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: Ref Label: Number of References Group: RefInfo Data: 24 – Name: DateEntry Label: Entry Date Group: Date Data: 2012 – Name: AN Label: Accession Number Group: ID Data: EJ957954 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1080/0075417X.2011.651842 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 17 StartPage: 32 Subjects: – SubjectFull: Verbal Communication Type: general – SubjectFull: Nonverbal Communication Type: general – SubjectFull: Self Concept Type: general – SubjectFull: Males Type: general – SubjectFull: Adolescents Type: general – SubjectFull: Case Studies Type: general – SubjectFull: Emotional Response Type: general – SubjectFull: Language Impairments Type: general – SubjectFull: Mental Disorders Type: general – SubjectFull: Psychosis Type: general – SubjectFull: Drug Abuse Type: general Titles: – TitleFull: Lost for Words: Difficulty Expressing Feelings in Work with Three Adolescent Boys Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Tyminski, Robert IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2012 Identifiers: – Type: issn-print Value: 0075-417X Numbering: – Type: volume Value: 38 – Type: issue Value: 1 Titles: – TitleFull: Journal of Child Psychotherapy Type: main |
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