Social Work with Youths and Adolescents

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Mirta David

2 approaches

Developmental -adolescence =transition b/w/ kids and adult

Psychopathological = what is wrong

Topics:

Theories

Freud

Erikson

Mahler

Bloss

-Sexuality/identity

-Criminality

Stanley Hall – 1904

-Coins the word adolescence

->his claims that it is its own separate period – is very defined

-transition between childhood and adulthood

-adulescere – Latin for growns + sickness

=implication = you can either grow or b/c sick in this period

-Since Hall, people relate more to adolescent period as its own period

Margaret Mahler:

-this is the critical period of developing autonomy = seperation from parents and

->Separation-individuation

Erikson: identity stage – identity is made

-2 trends

-drive t/w separation

-defenses against it (it is anxiety filling – loss of the familiar)

-that is why you see often negative feelings, storms, fights with authority figures

Bio-psycho-social approach:

  1. Freud – 1905 – sexuality and love: adolescence- the drive in sexuality increases hugely – therefore, adolescents feel sexually overwhelmed

-we might know the beginning of adolescence (i.e. puberty) – but be definitely do not know the ind.’s diff in its ending. – that is more psycho and social

-psycho end – range would probably be b/w 20-30

-the social entrance is different to every culture – sometimes, there is a ceremonial beginning (i.e. Bar-Mitzvah) and an end (i.e. driver license, army),

->though there might be huge difference and gaps b/w 3 sides of Bio-psycho-social

-in adolescence, there is a trial and error type of b/h.

-adolescence really depends on previous parental-kid conflicts

->i.e. job selection

what are the many tasks that the adolescent has to deal with?

  1. the dev. of the biological drives: the self is overwhelmed - body is changing and there are new drives: I gotta know my body and dev. and identity to fit to it
  1. Social adjustment: Erikson speaks about identity stage: meeting equals and peers and new social alliances ->gives him other source of reference ->new autonomy
  2. Internal world: does ind. have internal self-reference? (i.e. do I know what I want, what’s inside, etc? ->imp objs. (Good and bad objects) hopefully fill be constant-> can I make a diff. between them and me – are they consistent in me and I able to differentiate them and me and I am able to see parents’ good and bad and not all good or all bad ->try to integrate the splits we internally have
    1. Blos/Mahler: when separation starts –a lot of anxiety also to kid and also to parent
  3. cognitive change: move from concrete to more abstract thinking
  4. structural: the adolescent needs to be able to juggle between internal demands and external demands

1/11/06

which are the psychoanalytical/dynamic therories and how did they come about

-most try to be scientific

Bowlby: tries to be scientific by first looking at animals and inferring in to humans

-especially about mother-child rfelationships and the infant’s needs

Freud: discusses youth development, through observation of hysterical women.

->that’s how he diagnoses what is normal or abnormal

-speaks of developmental tasks. At age 5, we consolidate out identity as result of oedipal complex. Fixations (being stuck at a certain stage) occur if at a certain stage, the stage was under or over-satisfied

->through life, after age 5 we replay the fixations

Anna Freud/Winnicot/Melanie Klein observed abnormal kids and concluded about normal kids and their expected stages of developments

Using the developmental views:

Question: to what extent do all kids go through the same stages?

Answers:


Development factors that you have to consider



personality disorders

-we have to see how organized: (vs. function)



-we see huge gaps in different daily functions

->i.e. in Borderline personality disorder, interpersonal skills might be horrible while other functions (i.e. school) might be ok

-according until 18, can’t give personality disorder, yet we can give traits of XXX

note: adolescence is a biological/psychological/social

biological

-fast growth


-hormone changes

-secondary sex features


-influences growth/puberty changes

-huge bodily tension b/c hormones

-laufer+laufer spoke about adolescent masturbation b/c/ of this bodily tension

->they spoke about how fantasies are used to dev. a sexual identity


-just with the body changes, the kid might feel like loss of control

class – 8/11/06

4 models to understand the treatment of the adolescent:

  1. Freud


Freud:

-identifies terms:

  1. anxiety
  2. sexual ->our anatomy is our fate

  1. topographical
  2. dynamic/structural
  3. economical

model: drives: has 4 factors

  1. movement
  2. energy
  3. target
  4. object

-the drive wants to be satisfied.

Topographical model – mapping out the structures of the person

-there are conflicting energies based on 3 subsystems:

  1. id – instinctual drives that begin at birth – starts off as physical energy that eventually b/c emotional. People have instincts that they are born with them! There is Libido (life instinct) as well as tanatos -aggressive/destructive drives (also against the self). The id has no frustration tolerance. Does not have a reality tester. Is based on the principle of pleasure. The physical/emotional energy is here
  2. ego –the ego starts developing around a year and ½ - is role is to negotiate b/w id, reality and superego – has an organizing role. Has a self-preservation effect. Takes energy form id. Ego tries to function according to reality principle
    1. the ideal ego: what we want to do/expectations ->internalization if parents’ objects

defense mechanisms: ego develops them in order to avoid pain and reduce anxiety. They are automatic and unconscious and help maintain balance. They twist and deny reality. The purpose is adaptive by helping us deal with daily function. It only becomes unhealthy when we overuse them and with over-intensity

-the more use of one defense mechanism = pathology – i.e. paranoid = too much projection

2 kinds of defense mechanisms:


normal: someone who will use reasonably and rationally the defense mechanisms to deal with reality and come with a resolution to the problem w/o fixations

  1. superego – takes energy from id through superego ->here is the internalizations of parents (roles, etc…) the superego develops from the ideal ego ->Oedipus conflict resolution brings the development of the superego – the ability to check himself introspectively (lacked in antisocials)

3 kinds of anxieties

  1. realistic – dealing with objective, external sources of stress that give the subjective sense of anxiety
  2. moral – starts w/ superego threatening to overwhelm the person w/ guilt or with huge fight b/w id and superego (i.e. OCD – people are stuffed w/ guilt from superego of wanting harming people, so they ‘undo’ it w/ OCD. Behind the OCD is aggression t/w a person who is too threatening to show the anger)
  3. neurotic: the basis of the anxiety is from the id- dealing with forbidden drive – the tension b/w id and ego

-dealing with those kinds of anxieties leads to various solutions. Some bring pathology/symptoms and other s bring resolution

3 kinds of solution:

  1. healthy resolution of problem
  2. development of defense mechanisms to deal with those problems
  3. pathology


dynamic/structural

Class – 15/11/2006

-Freud’s psychosocial stage development.

-energy comes from:


-those drives goes through different erogenic parts of the body

how does libido connect to those body parts?

-libido goes to the body-part which is most related to the specific stage of development. Learns the world and important objects through those body parts and their psycho-developmental processes. If there’s a fixation, we’ll strongly see the fixations during stress

  1. Oral stage– 1st year of life - the baby learns the world through the mouth. The kid learns the survival functions of the mouth. I.e. breastfeeding ->there might be feeling of oral being too forceful entry - “no entry syndrome” ->later, won’t let objects and food in (i.e. anorexia) – but will also perceive anything as criticism (forceful entry of an object), even though there was no intention of hurting later in life
  1. Anal stage: 1-2 ½ year olds – libido b/c anal-bound
  1. phallic: 2 1/2 focus on sexual organs – they experiment with it – i.e. in kindergarten, they compare who pisses farther

relationship to dad is different for phallic boy and phallic girl


-Castration anxiety is meant to organize the boy’s internal life and to bring to suppression of the Drives. The resolution: beginning of superego.

-Freud bring the incest taboo as the beginning the of the superego

Every stage has a central anxiety

  1. Oral: fear of extinction – if I don’t eat –then I will stop existing! (doesn’t know what dying is)
  2. Anal: OCD – control/loss of something
  3. Phallic: castration


  1. Oedipal/genital: 3 ½ - 5-6
  1. latency: 6-10 – the person deal w/ other development – cognitive/social development
  2. Puberty: an age where the now-adolescent can choose a partner, outside the family cell. The choice is done Narcissistically (according to Freud) – we choose our love object according to how we were/wanna be/are right now

“the adolescent romance” (Freud) the person builds a narrative about our relationship w/ parents

Class – 22/11/06


13th of December

– no class, but instead

Aberastury theory

3 kinds of bereavement in adolescence:

  1. child’s body: I know that I am a boy or girl. W/ puberty, the changes are felt as a force-in into the self. The adolescent has to question what the future will be. I have to depart from my child body. I have to leave being child
  2. child’s identity: he feels that there is an end to being a child. The changes are still felt as foreign to him. the new identity is not yet integrated. New kind of sexuality which means adaptation/learning the new body. Ambivalence t/w the grown. Being sorry b/c of the growth: sense of chaos/confusion about the new body. There is anxiety over the changing body, and there is difficulty dealing w/ stress – feeling disconnected w/ body (even depersonalization). Thus some run to addictions.
  1. child’s relationship w/ parents: the parents are no longer seen as all-possible – there is a disappointment. Thus there is a search outside the family for intimate relations

Erikson

-offshoot of Freud:

8 stages of development



Stage Details Age
Basic Trust vs. Basic mistrust -get security through relationship w/ mom

–food/presence. Mom has to be there for him – if not, baby won’t trust his world!

 1 yr
Autonomy vs. shame/doubt -learns to control himself – if the baby gets reinforcements about his action will learn autonomy. –negative reinforcement will have doubt in his skills/weakness –which gets him guilt. This guilt makes him think that he can’t overcome his weaknesses 2 yrs
Initiation vs. guilt i.e. what you do in playground – the kid movements more –sees h.m. he can do – he might feel guilt about what he does – and thus ‘initiation vs. guilt’ 4 yrs
Industry vs. interiority i.e. learning/social techniques – if he feels that he didn’t learn social skills, he’ll feel inferior 6-11 yrs
Identity vs. confusion of roles

-‘moratorium’

 -adolescence

-trying to consolidate identity. If not, he feels social isolation/confusion.

The identity is really built throughout the stages. It refers to the past and present


identity: unity and uniqueness.

The integration of identity is through connection to significant others (increasingly same-aged peers) ->then need feedbacks to build their identity

-there is a tribe-like trend of social groups which tight roles which you have to follow. This is a defense against lack of identity (decomposition).

-with time, person also becomes independent from click-groups and form is own, unique identity

Erikson: identity is more important than Freud’s sexuality. I.e. in times of identity crisis, you can’t move on to next stages.

Only identity consolidation leads to real love and intimacy. No consolidated identity leads to self-destructiveness/decomposition/confusion/regression

Worse cases: psychotic/suicide

-Erikson’s definition of identity:

-defining what and who he is. What are his wants/opinions/ideologies/where was I and where will I go?

-integration of past/present/future

 12-18yrs
Intimacy vs. isolation -creating the family (marriage/intimacy) Young adults
Fertility vs. ‘congealation’ -Build the family Adults/generic
Ego-completion vs. despair Are you happy or sad w/ life’s achievements Old

Macia – 4 levels of identity:

  1. identity diffusion
  2. foreclosure: identity is accepted w/o testing
  3. moratorium –middle of identity crisis
  4. identity integration


Class of 29/11/06 – cancelled b/c teacher did not show up

Class of 6/12/06


-since eating disorder is not considered a psychological thing, they can't force hospitalization [after age 18]. The hospitals bypass this by saying that they have to force people into hospitalization b/c of body state

Definitions:

In eating disorder:


Factors in influencing eating disorder:


Etiology: factors leading up to eating disorders

-there a multi-factored cause for eating disorders:

  1. genetic/biological – the gene has not been found. On the biological level, you can see the serotonin: Bulimics have low levels of serotonin. Anorexics have higher levels of serotonin than normal. Many ED come with other stuff as well, i.e. OCD, mood disorders, etc. in Anorectics, you can't give SSRI b/f a certain weight ->for the anxiety
  2. psychological/personality: anorexia: low SE/internalized/perfectionism. In Bulimia: low SE/hard to deal with drives in general (i.e. high risk/impulsivity).
    1. Conflict theory
    2. Blos/Mahler – object relations
    3. Kohut-Self-psychology
    4. Behavioral/cognitive – very successful especially for bulimics
  3. Family – 60% of ED are those who suffered from incest/sexual abuse by family members – so eating disorder helps not deal w/ this pain.
    1. death and divorce in the family influences developing ED.
    2. Borders in the family: enmeshment – too few borders/disengaged – too rigid borders – when parents are too distant, then the kid takes on placing the parents closer to each other by b/c sick
  4. Cultural: mass media shows an ideal of thinness/social pressure to b/c that ideal thin/social messages of need for fixing the body. All of this touches deeply into the whole question of thinness. Added to this is the adolescent to become an adult. The kid could use the eating disorder t stop his growth. The boys who have ED often have identity disorder

Diagnosis:



13/12/06 class cancelled due to upcoming trip



Class – 20/12/06

-we had a case of a 40 year old, divorced and remarried, father of 2 anorectic. Still, his issues were adolescent - separation-individuation

-up to age 18, it is legally necessary to hospitalize+family therapy

-the food issue is a way to express the distress, whether over or under eating. The eating is so primal that it is really an issue that starts as a small kid. A secondary benefit is attention [of being sick]

-the treatment of eating disorders is usually with multi-professional task force/ when the disease of at it’s violent peak – therapy is more cognitive/behavioral; when calmed down, there is room for dynamic therapy. Need to decide what treatment approach/family therapy is necessary. We might want to evaluate the patient as well as all family system in order to see where the strengths/dynamic/pathologies/etc… so we can consider the treatment plan/family therapy

-more chaotic symptoms =reflects more chaotic life

Eating isorder places [for upto 18]


-average hospitalization is 3 months

characteristics of eatind disorder



DSM criteria:

Anorexia:

  1. refusal to upkeep normal weight for age/size and reduction of 15% of weight he was at 3 months ago
  2. fear of eating/gaining weight
  3. body shape distortion. Defines herself as fat when she’s underweight.
  4. Menarching stops for at least 3 months/men’s testosterone levels are low

Restrictive: the is a processes: slowly reducing several kinds of foods, one at a time, until nothing is eaten

Purging: through out what is eaten. Some anorectics have eating binges after which the compensate with purging – i.e. laxatives/gums/exercise

-1% of population is anorectic

-sometimes EDnos, the diff. might be that there is an exception in a clause – i.e. she is menarching

Personality characteristics:


Bulimia

  1. Episodes:
  1. repeated episodes of binge eating [eating within 2 hours] the amount of food bigger than most of population would eat in similar situations. [b/w 2000-10,000 calories]
  1. sense of loss of control over the food [self-report] over time. The sense that the person can’t control how much or what he’s eating
  1. inappropriate compensatory behaviors to avoid weight gain. i.e. laxatives/exercise
  1. at least 3 times a week for minimum 3 months
  2. SE is related to weight/body shape in an inappropriate way

Purging type: -this is bordering on anorexia – usage of laxitives/etc…

Non-purging types: after binge eating, using restricting things, like fast/sports but non-compulsive

Characteristics:


class 27/12/06

-we’ll speak about the family

Bulimia Cognitive cycle:


cycle

-low SE->over-worrying about body->excessive dieting->want to fix SE problem ->excessive dieting->hunger->bulimia->low SE

-the diet is meant to show that I am at least good at something

-the cycle feeds itself: bulimia increases worrying about diet. The diet is so rigid that any deviance from the diet affect the SE. thus the bulimic tries to compensate w/ the purging/non purging activities of the bulimic. The key issue here that the bulimic is trying to get control, yet her way of achieving this makes her actually lose controls. The issue here is really not weight but control

Physical problems:


Family problems:


-now, we’ll speak of the 2 other ED:

Binge eating disorder:

-repeated eating binges


additional characteristics include:




EDnos

-the younger ED usually has anorexia. Older kids usually have bulimia

  1. have most criteria of anorexia, except the fact that she does have a regular menstruation [man’s tests include testosterone levels]
  2. all anorexia symptoms except there is a fast decrease in weight, but the currant weight is still normal ->for example -3 days of being anorectic [control] and 3 days of bulimic [loss of control]
  3. could throw up less that 2 times a day or for less than 3 months
  4. some of the compensatory b/h could be even after smaller amount of time



important issue of all ED issues:

-food issue is used to cover up emotions, whether done w/ food avoidance or eating instead of feeling [binge eating]

Psychopathology of individual of individual vs. pathology of a culture

-out culture has a central obsession w/ woman’s body/food

-this led to women being very confused – women use food as a means to taking care of others [i.e. baby]. Thus there is a link b/w food and interactions

-with time [usually when kid is young] the satiety function is ruined – i.e. mom doesn’t read the baby right about satiety

-we can see that in times of les food, fatness is seen as beauty – it was the sign of fertility

-as seen in Fiji – anorexia starts w/ introduction of media

-equality gave woman the another status – marriage age went up/woman need to be increasingly active in other roles except parent. Thus anorexia is a woman things since she has so many roles.

-80% of woman have the SED syndrome – sub-clinical eating disorders/ those women are worried about their weight. Their weight goes up/down. They try to limit themselves

Class 3/1/07

-today, we’re gonna speak about ED therapies and problems in therapies

kinds of therapy


Psycho-educational therapy:

-integrates emotional and informative elements. It educated the client and actually the whole families about the disorder. Very similar to CBT, but has educational emphasis

3 principles in psycho-educational therapy of ED

  1. giving info
  2. fixing distorted views/attitudes/denial. For example, give knowledge that there is no freedom of choice here in the ED->basically giving info and then changing the views based on more informative decisions
  3. transferring responsibility for the situation to the family/client

-often, information could be a good basis for other kinds of therapy – this usually happens during intake

Cognitive-behavioral treating of ED

2 elements

  1. behavioral – often done by dietician. Dietician tried to fix wrong info about food/.eating/damages to body/reduce secrecy about food. Thus, dietician is perceived as bad. – ment to deal w/ behavior around food

-In chaotically sick ED clients. The info of Behavioral/psycho-educational therapies help to organize

-often ED clients, we can see parallel b/w chaocity of pathology and chaotic life

  1. cognitive

psychodynamic therapies

-this is long-term – at least 1 year to start seeing how to start organizing life

-some focus on relationship b/w therapist/client in helping controlling drives

Model 1 – drive theory

-usage of drive therapies. The disallowed drives are defended against by the ego. The symptoms are result of defending against those forbidden drives. Freud said: the ED is a defense against oral-sadistic drives.

Model 2 – object-relationship

-Mahler – the ED is based on separation-individuation problems

-> with time, we expect kids of separate from internal/external parents. The ED is conflicted b/w the 2 views [those who cut their wrists: I’m killing my internal parent]

Model 3 – self-psychology

- Kohut

-focus on the self. ->in order for child to develop well, parents need to identify his basic needs: need to mirror the child – i.e. the child learns about himself through how his mother reacts of him [kohut took it to narcissism]. If mom listen to child’s needs, child will develop better/more cohesive self. The child will take his space w/o fears

-in ED, the anorectic takes her space in the world by disappearing. The obesity person, there is a huge gap b/w size and internal feeling of being small

-there is an emphasis on:


-self object is called זולת-עצמי

-Kohut basically said that there is an empathy and interpreting stage. With the chaotic patients, be more empathic than interpretive –i.e. identify regressive/narcissism needs of patient

goals of self-psychology:


-fills self with the food self-object and controls it! [i.e. anorexia]

-anorectic is at the link b/w grandiosity and depression ->she feels grandiosity over controlling over basic drives. the basic feeling here is of grandiose winning

-use transference in therapy to get client to trust other self-object than food

-help use her own eyes and not through internalized eyes of others

Interpretation:

-seeing the relationship b/w symptoms and other things, like transference/life/etc…

->Kohut – you can only do so when client feels safe enough

3 kinds of transference according to

1) mirroring: also done b/f

2) idealization: there is something healing about seeing the therapist in good views – it allows for identification, and in return the client also attributes to himself good characteristics, and this is healing [b/c I go to him for therapy and something sticks from him to me in my therapy] – this is especially true for a broken self

Class of 10/1/2007 - cancelled

Class 17/1/2007

Class:


-therapy has an element of trust/dependency – this is opposing to adolescent’s urge at separation. Another issue is the emotional cathaxis t/w the therapist necessary for therapy which the youth is at the midst of trying to emotionally detach from parents. Also, therapist needs feeling weakness of some sort while adolescents feel omnipotent


-read suicide in apter book – 209-216 in chapter 16

Test: has 3 parts:

-multiple choice questions – 40%

-definitions – 30%

-open questions – 30%


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