A psychoanalytic approach to a therapeutic impasse with an impulsive adolescent: permission to speak the unspeakable

The authors describe an impasse in the therapy of an impulsive, intermittently psychotic adolescent boy and demonstrate the usefulness of understanding the impulsive behavior according to the classical psychoanalytic definition of "acting out." Rather than being viewed as a random breaking through of impulses, this impulsive behavior can best be understood and clarified in the course of intensive psychotherapy as classical acting out under the influence of the therapy and the transference. With impulsive patients of this type they have observed a strong tendency to abandon this basic psychoanalytic formulation and the use of the verbal interventions that follow from them. Such patients often need encouragement to remember and express their painful feelings in words instead of repeating the entire emotional experience in action. The authors also describe the resistances within the treatment team that interfered with the development and utilization of this basic psychoanalytic formulation.