Some Problems Concerning Adolescent Psychiatric Patients
- Author:
PICKFORD, M.A., Ph.D.(Cambridge), D.Litt.(Glasgow)
Lecturer on Psychology in the University of Glasgow introduction
It is easy for the psychiatrist to refer young patients who come his way to a child guidance clinic, and this is done regularly. With adolescents who are too old for child guidance treatment, and who are not old enough to be sent to an ordinary clinic for treating nervous disorders in adults, there is a problem of considerable magnitude, and it is specially to this, and to the large influence of the transition from school to employment as a precipitating factor in ” nervous ” troubles, that attention is drawn in this paper.
Seven cases will be mentioned very briefly, one third of the 21 children and adolescents referred to a psychiatric out-patients’ clinic in the year 1944. In these seven cases transition to employment was a large factor in causing ” nervous ” difficulties. The main part of the article will be devoted to a discussion of some practical problems about the approach to such patients and their treatment, and of the interest of mental tests to the psychiatrist.
Case Histories?Brief Summary
(1) A boy, aged 16 years, a ” hand ” in a lard works, refused on two occasions to go to work and also disobeyed his mother. He was “jumpy ” in bed and at times failed to notice things happening in his environment. He was under the probation officer, because when 13 years of age, some boys from another school had stolen some coats which they made him pawn in his name.
(2) The second case was of a girl, aged 13? years, and still at school. She was sent to a psychiatric out-patient clinic by her family doctor because she felt sick and was unable to go to school. This proved to be an hysterical resistance against the need to choose an occupation. Six months later she gave up a music examination because anxiety interfered with her practice.
(3) A boy, aged 15A years, was referred by his family doctor because he was ” afraid of things ” and was not attending to his work. He was worried because he was shown how to do tasks only once, and this was not sufficient’ for him. He was told he was ” daft ” because he could not do the work, but it was by no means clear that lack of intelligence was the real difficulty. He was very depressed and spoke only in monosyllables. (4) A boy, aged 16 years, a munition worker, had been referred to a psychiatric out-patient clinic, for deafness, by a neurologist who found no physical cause for his trouble. The deafness had developed suddenly one night when he returned from work, and he knew in addition of blanks in his memory, one of which lasted four days. At the time of examination he was normal again, but the psychiatric report suggested an hysterical condition.
(5) A girl, aged 16, a biscuit tin labeller, referred by her doctor for lack of concentration during the previous six days. She had been a normal child and got on well at school, but had difficulties at her work after leaving school. In one job as a typist she was too lonely. In another job as a saleswoman, she found it too trying to set out goods for the customers when nothing pleased them. In a hairdresser’s establishment she burnt her hand and left precipitately. Her present job she liked quite well.
(6) A girl, aged 15 years, previously employed in the office of a hospital. She was referred by her doctor for leaving her work without explanation. She started to take days off and later took a whole fortnight off work, going out and coming in at the usual times, but going to friends’ houses and saying she was on holiday.
(7) A girl of 15 years of age, Intelligence Quotient 124, a typist. Her family doctor had referred her for ” telling lies for being lazy and for failing to keep up a normal standard of personal cleanliness, through which she had lost her job. This was a very interesting patient. She was the illegitimate child of a girl of 16. Her father was 19 at the time. Her mother had married since, and she hated her step-father. Unwanted, this child had been petted and made much of by her mother and grandmother, and had been told stories about her parentage which must have been unconvincing to a child of her intelligence. Subsequently they were found to be untrue, but she had much imagination and learned to tell fantastic stories from her grandmother’s example.
Suitability of Clinics
The question of suitability of clinics for dealing with adolescent patients, who are just starting work, is important. Most of them will be too old for an ordinary child guidance clinic. They cannot be placed satisfactorily in the normal therapeutic playroom, with children between 5 and 10 years of age. They require a more adult type of therapy ? than the usual playroom provides. A new type of approach might be invented, and many of these * I am indebted to Dr Angus MacNiven for permission to publish this article. R.W.P. patients could be handled more easily at a clinic for adults. At the same time it is probable that therapy for such adolescents would be more likely to take the form of co-operative games and projects, which are developed from the essential principles of the therapeutic playroom, but which are more systematic and purposeful. It would be best if such activities were in the hands of supervisors who are not direct representatives of the home, of the school or of the employment, because these are the very institutions against which the child rebels or upon which it is unduly dependent.
Supervisors must have psychological insight and be able to understand when discipline on the one hand and indulgence on the other would be helpful and when harmful to each individual. It would be easy to envisage the development of a special clinic for adolescents, in a town of say 50,000 inhabitants, and perhaps attached to an adult rather than to a child guidance clinic, but certainly not to a school. Such a clinic might take the form rather of an instructional and social centre, which could be worked into the normal steps from school to employment for children of unstable temperament. With the raising of the school leaving age, institutions of this type might become even more valuable, and might be parts of the scheme for transition to employment from school and home.
The problem is different from that of handling malefactors or delinquents, and is one concerning the maladjusted rather than the anti-social, though it is closely allied to ‘these problems. None of the patients mentioned here had appeared in court, was uncontrollable or had come into the hands of the police, with the exception of one boy whose contact with these officers was due to other boys’ delinquency and not to his own. Nevertheless, if their physicians had not had the wisdom to refer them to a psychiatrist, contact with the police, and possibly appearance in court, might have been the next development for any of them. They were more inclined to escape into neurosis than into delinquency. If seven out of 21 children and adolescents under 17 years of age who were referred to a psychiatric clinic were in difficulties over employment, there must be a great number who could be helped if attention could be directed to their problems. As it is, they drift unsatisfied from one occupation to another, a worry to their employers and parents, they add to the bulk of wasteful labour turnover and often end in unhappy situations of a serious nature Thus it would seem that methods of group therapy might be developed and adapted to meet the needs of such children, but a psychologist able to grasp and handle their peculiar attitudes and difficulties would be needed to do it.
? The Need for efficient Mental Testing
The mental testing required in a psychiatric clinic is chiefly intelligence testing, though diagnostic and temperament testing would be useful, and vocational aptitude testing would soon become important where suitability of work was under consideration. With certain exceptions every patient should be given intelligence and projection tests. These exceptions are the patients whose anxiety, depression, excitement or other symptoms are so severe ‘as to make the test impracticable or its result unreliable. However, they should be tested as soon as they are well enough, and in spite of the difficulties it would often be instructive and useful to carry out a test while the patient was too ill for it to be reliable, and to compare its result with that of the same test under better conditions. Those who come to a clinic more than once, or who are in hospital for a period, may be tested at intervals, and the changes in result may be considered in relation to the improvement or deterioration in mental condition. To carry out all this work efficiently would call for a special psychological unit in every mental hospital.
Testing is important for adults, but for children and adolescents it is essential. The writer would be the last to suggest that tests will ever be substitutes for the skilled interview or the intuitive approach to the patient, and in psychiatry this is less likely to happen than in any branch of medicine, but mental tests, especially intelligence tests, contribute something very important to the approach to the patient, while projection tests lead naturally into therapeutic treatment.
From a brief consideration of the seven cases mentioned in this article, it is clear that the intelligence of every patient is a factor which bears on the problems of his treatment. Until we know the intelligence quotient we cannot tell how far difficulties with work are caused by intellectual and how far by emotional factors. Difficulties with work caused by intellectual inadequacy might lead to the production of neurotic symptoms. In treatment it is clear that a better response may be expected from those patients with higher intelligence, other things being equal. Projection tests and other diagnostic and temperament tests are valuable supplements to the psychiatric interview. The war has led to the discovery that, where large numbers of individuals have to be examined for training, simple pencil and paper tests taken by groups will serve to select a large proportion of those who are unstable or temperamentally unfit. Even homosexual tendencies may be revealed by comparatively simple verbal tests. In civilian practice the use of projection and temperament tests will be mainly individual, and they will serve to give a background of objective data to support the clinical findings. Mental testing is not an end in itself, and it can be overdone very easily. The psychological tester should certainly not be relegated to the position of a machine for producing test results as a pure routine. He should be expected to have as much insight into the clinical problems as the psychiatrist should have into those of testing, so that cooperation between them may be sufficiently close to be of a constructive character.
Effect of Entry upon a Career in certain Individuals The next problems are how and why the entry upon a career or employment should have a disturbing effect sufficient to precipitate neurotic or even psychotic conditions in certain individuals. The entry upon a career is a form of developmental transition, involving separation to some extent from home and school influences and the partial breakdown of these dependencies, or the threat of such breakdown. In addition, the adolescent phase is one of considerable disturbance and of threatening emotional changes. Hence, it may be that the confidence given by the patient’s customary supporting attachments to school and home are partially withdrawn at a critical phase in his life. Not only is the pressure brought to bear upon him to accept the coming transition towards maturity in himself, by going into the world of careers and occupations, but also he is expected to accept this pressure along with a reduction of his normal emotional supports. The result may be a very considerable disturbance of the balance of impulses and emotions within the personality. This is a special risk in persons whose childhood or infancy has been marked by disturbances or inadequacies, or whose home life has been broken and inharmonious. Just as thpre is nothing which succeeds like success, so there is nothing which fails like failure, and the result of a disturbance in adolescence may be a repetition of previous failures in a new setting, often coupled with compensatory neurotic tendencies. Such tendencies arise because there is a compulsion to restore the balance in any possible way when it has been upset, and the individual may turn unconsciously towards childish or infantile regressions which offer even temporary and inadequate compensation. Hence the neurotic and even psychotic symptoms. They are the product of the repetition of infantile failures and of the craving for a restoration of the emotional balance, and they are abnormal in the sense that they do not provide an adequate mature adaptation. The aim of therapy will, therefore, be neither to moralize (which has usually been tried to excess before the patient appears in a clinic at all and which brings thereby even more pressure to bear where there is already too much), nor to attack the symptoms themselves as if they were the illness, but to bridge the gap in some temporary way while the individual makes the necessary re-adjustments for himself. The natural tendency of the mind to create its own re-adjustments is the psychiatrist’s greatest remedy, just as the work of the physician and of the surgeon’s consists mainly in setting up conditions in which spontaneous physical healing can take place.
Treatment of these and Similar Cases
There are three points of application of treatment: (a) to the patient personally; (b) to the patient’s home; (e) to his employment, or, if he were at school, to the school. In general the order of importance of these points of application is the order given. If the patient is intelligent and co-operative, much can be done by discussing the conditions of the breakdown with him and by guiding his ideas into a direction of greater tolerance of the anxieties involved. In doing this, the therapist in reality proceeds by taking upon himself to some extent the burden of dependencies which the patient has been forced to withdraw from home and school and has failed to attach to his work. The therapist must grasp that, whatever overt technique of treatment is exploited, even if it involves hypnosis or the use of sedative drugs or reassurance, this acceptance of the patient’s freefloating dependencies is the essence of the treatment. This is interesting, because modern medicine tends to be very materialistic, and this is one of the main reasons why so many people like to go to ” quacks ” of various kinds, who are often experts in manipulating personal sympathy in exactly the right manner. The physician only too often looks upon treatment as a mechanical process like replacing or repairing broken or worn parts in a motor car, and the favourite dictum, ” Mens sana in corpore sano is in many cases precisely the opposite of the truth. The exact manner in which the patient’s dependencies are to be handled varies greatly from case to case, and no specific rules can be laid down. The method must be determined by the therapist’s own insight. It must always be kept clearly in mind that subsequent detachment of the patient and the re-orientation of his emotions about his work is essential and must be the real aim of treatment, to be achieved as soon as possible. The therapist is merely a stepping-stone. With many cases, such as those described in this article, where the illness is not very severe or incapacitating, there is much hope for the use of group therapy, a form of which would be excellent for adolescents if it included games and social projects of a constructive character, and avoided influences emanating too strongly from the home, school or employment. Such treatment could be approached through the family physician and the psychiatric clinic much more successfully than through the school or business. The treatment, whether group or individual therapy, must be able to tolerate and even to exploit aggressive and hostile attitudes and feelings on the part of the patient, and to meet them with the requisite indifference, sympathy or humour, and not with repressive discipline. It is likely that some aggressive patients will be unconsciously craving for punishment in certain ways which must be understood.
Next, the patient’s home, is always likely to be a difficult problem. Not only have the conflicts of the home necessarily been (at least in part) the causes of the patient’s difficulties, but also members of the family will be sensitive about the patient’s illness and his delinquencies, if any. They will need some re-assurances, which will be the first steps in the therapy applied to the home. This therapy will have two aims, the first of which is to help the patient through the home and the second to help the home itself, because the patient cannot be helped through the home unless the anxieties and conflicts of the latter are to some extent reduced. Treatment of the home for its own sake would become a further aim if the members of the family came forward for help. Treatment of the patient through the home will always be a very difficult matter unless exceptional understanding is met there. An expert social worker will have to cooperate with the psychiatrist and psychologist in order to deal with the home, and there is no doubt that this kind of work is very important and ought to be developed. A thorough grasp of modern psychology and its methods will be the foundation of the social worker’s training. Not only psychiatry, but also mental testing, social psychology and many aspects of educational and industrial psychology will be relevant and cannot be overlooked. The part played by the social worker will be more than to visit, investigate and report. She must be able to help the family to express and discharge anxieties and hostile feelings excited by the patient and directed upon him, and perhaps upon the psychiatrist and the clinic as well. To do this requires much insight into human emotions and their conflicts, projections and repercussions, and an ability to remain detached herself and sympathetic without being unconsciously manoeuvred into position (possibly against the psychiatrist and patient) by members of the family. Many and complex problems are raised by these observations, and they cannot be dealt with here.
The final consideration is the approach to the patient’s employment. This will involve two problems, first the manipulation of the employer’s sympathy or hostility to the patient, and secondly the question of vocational guidance. The employer’s sympathy should certainly be won wherever possible. There will be various complications. Often it may be helpful to advise that a patient should escape from the family by going into an institution, or that he should leave home for the more co-operative custody of an aunt or more distant relative, or even that he should leave the aunt’s or grandmother’s protection so that his parents shall shoulder their own responsibilities. On the whole, the home and relatives are more or less immovable stepping stones or barriers to progress, and the patient must be helped in his dealings with them.
The employer (or school) is generally a less fixed quantity, and it may be fortunate that both he and the kind of work can be changed. Sometimes it may be an advantage to encourage the patient to persist in the same work, and then the attitude of the social worker will be that of winning sympathy for him from the employer, always explaining in a way which can be understood the nature of the illness and the extent to which sympathy is likely to be helpful. Where it seems better to advocate a change of employment, then selection of a suitable job becomes an important problem. All the resources of vocational guidance, depending on appropriate interview techniques, intelligence and diagnostic tests and tests of special abilities, consideration of preferences and temperamental qualities, must be brought to bear on the matter. With the selection of a more suitable occupation a better adjustment to work will be gained and will play an important part in the treatment, because suitable work will sublimate and dispose of conflicts instead of aggravating them. The re-assurance of a successful transference of the patient’s dependencies to a useful and interesting occupation will play the most important part in the cure.
Conclusion
This article deals with seven adolescent patients referred to a psychiatric out-patients’ clinic for “nervous ” symptoms which interfered with their work. They formed one-third of a group of 21 children under 17 years of age, taken consecutively during 12 months, the remaining 14 of whom were referred for other difficulties not connected with employment. It is pointed out that the phase of transition from school to employment is liable to bring emotional stresses which can precipitate disorders of a neurotic or even psychotic character. This transitional phase and its possible consequences are worthy of special study, and a development of child guidance and play therapy, organized along more adult lines, might be worth attempting. This would be a form of play therapy, and would meet the difficulty of handling difficult adolescents who are too old for child guidance and too young for clinics for adult nervous patients.
It is suggested that the reason why the transition to employment is sometimes a traumatic event may be due to the disturbance of the balance of dependencies between home and school, which it may upset at a critical time. The patients liable to this form of disturbance will be those who have an unfortunate background in infancy and childhood, broken homes or the failure of an adequate balance of emotional attachments at an early age. The therapist’s aim will be to restore the balance in such a way that the employment becomes a valuable sublimation instead of a threat to security. The patient, his home and work will be approached in a therapeutic way, and occupational guidance will be a special interest. This article stresses the need for adequate mental and diagnostic testing by psychologists in co-operation with the psychiatric clinic.
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