The following five factors identified in the clinical presentation assist in making a diagnosis:
1. The defenses the patient uses against abandonment depression.
2. Separation experiences in the patient’s interpersonal relationships, friendships, and how the adolescent perceives and experiences separation.
For example, an adolescent girl presenting with an eating disorder interpreted a one-day disagreement with her rather rebellious friends as a catastrophe and said she did not know how she would survive it.
What she described as “separating from her friends” was actually her constantly demanding that they message her, and her friends reporting that she was overwhelming them. In this case, the 16-year-old adolescent intensely desired extremely close—even fused—relationships, and when the other side reacted, her world collapsed. Considering that eating disorders often correspond to a very early oral fixation period, these data can be integrated in diagnostic formulation.
3. The patient’s history of narcissistic oral fixation.
4. The parental profile—parents with borderline personality organization or even full borderline pathology. Generally separated parents or parents engaged in sadomasochistic relationships. Their character structures and parenting capacities are important. For example, during a family session with a 16-year-old male adolescent I was following in the clinic, the father said, in a childish and tearful voice, “But my son hits me, he beats me.” During the session, when the adolescent began yelling at his father and I asked him to step outside so that “we adults” could talk, he said “okay” and left the room. The father was surprised and said, “If I had said that, I would have been beaten.” He admitted that he had never been able to set limits for his son and was afraid to do so. Many adolescents with this pathology have stated, “Sometimes I need someone to forbid things, but there is no one at home who can do it.”
5. The family communication style—communication at home occurs through action, not words. Writing and behavioral expression.
Diagnosis
Two points must be considered: defining the present acute symptomatic condition and investigating whether this condition existed in the past, going back up to 4–5 years.
And examining the underlying structure that produces this symptomatic episode.
Current Illness
The key point for diagnosis is not the subjective symptoms the patient reports, but the acting-out behaviors that everyone sees but the patient is reluctant to report.
- Disciplinary punishments at school
- Substance use
- Alcohol use
- Theft and other criminal acts
- Any legal incident
The adolescent patient does not tell us they are depressed; they simply try to avoid all these events. They deny, avoid, escape—but during early confrontation they also ask for help.
Therefore, it is necessary to meet with the families of these adolescents at the start of treatment. Since many of these families have borderline structures—mild or severe—their own denial and guilt may prevent them from recognizing their children’s behaviors, or they may unconsciously provoke these behaviors as a way of achieving emotional gratification. Therapists working with such cases will encounter strong resistance and denial when taking personal histories.
It may take months for the patient’s acting-out to diminish, for depression to surface, and for the real stories to emerge. When parents begin to work through their guilt more deeply, the underlying truths become visible.
The Patient’s Defenses Against Abandonment Depression
What kinds of acting-out appear when the situation is pressed tightly?
It may begin with mild distress, restlessness, difficulty concentrating at school, hypochondriasis, excessive activity (sexual—masturbation—or physical). Eventually, more striking forms of acting-out appear—antisocial behaviors, theft, drinking alcohol, marijuana, heroin, glue-sniffing, random sexual encounters, running away from home, skipping school, driving recklessly, car accidents, gothic dressing, hippie-like behavior, and suddenly adopting an extreme peer group. These friends become perfect projections of the parents’ guilt about their role in the adolescent’s difficulties. Parents deny that the problems originate at home and insist the adolescent is the “victim of bad friends.”
However, in adolescents with this pathology, the opposite is true. They insist that their friends are not responsible and that no one can make them do anything they do not want; they emphasize that substance use is entirely their own choice.
Another form of acting-out is replacing reunion with the mother figure through sexual relationships—forming dependent relationships with older men or women. When examining the clinical history of acting-out, the diagnostician must remember a few points—for example, in schizophrenia acting-out may defend against psychosis; in neurosis, against anxiety; in borderline pathology, it defends against feeling depressed, abandoned, helpless, and hopeless in relation to separating from the parent.
Behavior as a Cry for Help
Adolescents are known for their reluctance toward treatment. Continuation in therapy is more difficult than in adults. Rogers noted that “these adolescents need to reject therapy before they can eventually accept it.”
The refusal that emerges from the conflict between passivity and activity becomes the first step toward eventual therapeutic acceptance. Over time, these adolescents become more engaged in therapy. The initial refusal is actually a testing behavior, examining the environment to which they may eventually surrender control. This boundary-testing is especially common in borderline adolescents.
What brings these adolescents to treatment is usually a series of escalating events that break through the parents’ unawareness—stemming from their inability to see their child as an adolescent in trouble.
The adolescent is drowning in this stormy sea of internal struggle; as they sink a third, perhaps final time, they cry out for help.
The long history of such behavioral “calls for help” demonstrates the strength of their resistance. Each behavior receives parental indifference, causing the adolescent to escalate to more dramatic actions until intervention finally occurs—usually not through the parents, but through a friend, teacher, police officer, or judge.
Parental resistance also affects the first communication with the therapist. They are often not searching for “the best doctor,” but for a doctor who can offer treatment without touching the issue of separation from the adolescent. This forces the therapist to be cautious; for example, mentioning anxiety too early may cause the parents to abandon therapy immediately.
Note: Families of such adolescents often hide their own problems behind the adolescent’s pathology or try to manipulate the therapist beforehand. The most common example is a parent calling the therapist before the adolescent’s first session, requesting a separate pre-meeting. Just like the phrase “bad friends corrupted my child,” they try to influence the therapist by overemphasizing the adolescent’s faults. For example, a recent case involved a 15-year-old girl whose parents found videos of her cutting herself and wanted to bring the videos to me; I told them it would not be appropriate. Such manipulations are common.
When I suggested to several parents of borderline adolescents that they themselves needed separate therapy or couples therapy to cope with the process, some temporarily improved, while others refused to see any other therapist. In such situations, the borderline adolescent proves to be more resilient and stable than the parents.
Thus, the clinician must approach the adolescent differently. It is crucial to perceive the urgency and underlying anxiety that the adolescent cannot verbalize. The therapist’s response becomes a life preserver, just like the lifeguard who jumps into the sea. This response keeps the adolescent afloat until therapy can begin.
Borderline adolescents and their families lack the capacity for verbalization and symbolic expression; therefore, they constantly argue, fight, curse, or at best communicate by writing. Consequently, they communicate with the therapist through action or silence. If seen as a family early in treatment, the session will consist only of shouting and action—it will have no verbal or reflective content. In one hospital session, a borderline adolescent seized control, insulted the therapist, slammed the door, and locked themself in the bathroom. Emotions are not expressed verbally; distress is not described—it is acted out. These adolescents initially signal their behaviors to parents, but if unnoticed, the intensity escalates until it becomes impossible to ignore. For example, a 16-year-old glue-addicted adolescent sniffed glue for weeks in his room without parental intervention; when still unnoticed, he stole a large sum of money, eventually resulting in legal consequences.
Another adolescent’s story: A 15-year-old girl lived with an extremely controlling mother after her parents divorced when she was six. The mother believed her daughter should have no private space—her room door had to remain open, she read her daughter’s letters and diary, and interrogated her over the slightest concern. The girl had no privacy. This was not responsible parenting, but rather an enmeshed relationship that obstructed the girl's individuation. As a result, depression began, grades dropped, and she distanced herself from the family. The mother ignored the depression and increased academic pressure. Truancy, behavioral problems, and disciplinary actions followed. Secret alcohol and cigarette use began—she consumed alcohol rapidly in dipsomaniac fashion. Then she disappeared from home for two days. Eventually, school authorities noticed the distress and referred her for treatment. These systematic, escalating behaviors—depression, declining grades, truancy, disciplinary issues, substance misuse, running away—were all cries for help. The therapist must “read” the adolescent’s communication in these behaviors, not search for verbal motivation. Failure to do so will repeat the same disappointment the adolescent experienced with parents and likely result in therapy dropout.
