Within or without: negotiating psychic space with an adolescent at risk of developing a narcissistic personality structure

This paper examines a 22-month once weekly psychotherapy with an adolescent young man. My patient was one of a group of adolescents who, due in part to excessive aggression, envy, anxiety or confusion, has chronically evaded the intimate and dependent psychic contact with others that is necessary for psychological development. In my view, this comes about through a combination of external factors and internal predisposition, with the quality of care received during infancy playing a crucial role. These adolescents appear to be developing narcissistic modes of being in the world which if allowed to persist into adulthood would be seen as deeply entrenched clinical psychopathology. Managing separation and loss is one of the central aspects of adolescence, but these young people tend to intrude or merge with others with such aggressive force that recognising difference between self and other becomes difficult. In psychotherapy, this often takes the form of the patient’s inability to tolerate experiencing the therapist as a separate person, and when knowledge of the therapist as separate impinges on their view, they frequently react in a variety of primitively destructive ways. This paper seeks to explore these central ideas through a detailed examination of psychotherapy with a young man in whom such struggles predominate.