Case Example

Six-year-old Betsy was referred for psychoanalysis because of her inability to adapt to many age-appropriate expectations. Her parents, though loving, had had little ability to set any appropriate limits for Betsy: She was not expected to go to bed at any particular time, she watched unlimited television, she ate only what she wanted and when she wanted. Weekly meetings with the parents helped the clinician understand the severity of the parents' own conflicts around aggression; the parents experienced any limit setting as dangerous and cruel. They recognized that their daughter was ill-prepared for life outside the family but felt quite helpless to do anything about it. Clinical evaluation revealed that Betsy was a bright child who was unusually comfortable at retreating into her own fantasy world of happy, magical fairies whenever reality made a demand on her. Betsy expressed a high level of anxiety about how dangerous the world outside the family was; she found it hard to concentrate in school because of her preoccupation with the idea that a fire might break out. She was equally concerned with the idea that the weather might suddenly and inexplicably turn seriously bad; in her mind there was a constant possibility of tornadoes or catastrophic storms. When she had such thoughts, Betsy quickly turned away from reality and withdrew into her magical fantasy world. The evaluating clinician viewed Betsy as a child with clear ego vulnerabilities, particularly in the realm of tolerating frustration, delaying gratification, vulnerability to ego regression under the press of her anxiety, and a reliance on a retreat from reality as a primary mode of defense. The clinician felt that once- or twice-weekly psychotherapy would prove inadequate to addressing the severity of these vulnerabilities because of the comfort Betsy experienced in withdrawing from the demands of reality. It was felt that only with the development of an emotionally significant relationship with the analyst would Betsy be able to tolerate the level of anxiety she experienced and become able to relinquish her reliance on such primitive modes of defense.

As suggested earlier, adolescence may be the most difficult period of development in which to engage a youngster in a close therapeutic relationship that involves self-revelation. Although the diagnostic indications are similar to those described for younger children, there must be a particular urgency, either from the adolescent himself or herself or from his family or community that is necessary to sustain an analytic treatment in this phase of development. The analyst's recognition of the normative developmental demands that pull the adolescent away from an intensive therapeutic process require a level of flexibility with regard to frequency and continuity of treatment even when the adolescent has agreed in principle to its necessity.

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