By 1968 about half the people in the United States will be under twenty-five. One-fourth of all psychiatric clinic patients are now adolescents. The National Institute of Mental Health has calculated that if the present rate of increase continues, the number of young people in mental hospitals will double in the next decade.
The diagnosis of emotional disorders in young people requires considerable discrimination. Adolescents often present a fluctuation of moods that may resemble incipient or active psychopathology. Anna Freud has warned against the tendency to identify common adolescent phenomena as forms of mental illness: “The adolescent manifestations came close to symptom formation of the neurotic, the psychotic or dyssocial order and verge almost imperceptibly into borderline states and initial, frustrated or full-fledged forms of almost all the mental illnesses.… Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life” [“Adolescence,” Psychoanalytic Study of the Child, XIII (International Universities Press, 1958), p. 275].
The evanescent mood swings of adolescence must be differentiated from the lingering, more sinister alterations of personality that may signify more serious disorder.
The concept of identity crisis elaborated by Erik Erikson has widely influenced adolescent psychology. He regards the search for identity as one in a series of developmental crises in the growing person. As one crisis is resolved, growth proceeds in healthy fashion to the next. The establishment of a sense of identity he calls “the great task of late adolescence.” As long as the establishment of identity is incomplete, identity-confusion is said to exist at a conscious level. Failure to resolve the quest for identity may lead to pathological disturbance at a deeper level; this Erikson calls identity-diffusion.
The philosophical assumptions of Erikson’s writings are important both to the adolescent who takes them as his vade mecum on the identity quest and to those who aspire to be helpers along the way. Erikson describes his theory of ego-identity as being “safely anchored in systematic clinical investigation and in psychoanalytic methodology,” adding, “We can use it as a platform for going in either direction when the need arises.” That psychoanalytic theory is based upon psychopathology—accepting “deviations as the measure of all things”—is a weakness Erikson well recognizes. The tie to psychoanalytic theory is a methodological option he has taken to provide a theoretical framework. But the salient aspects of the adolescent struggle were well known long before the advent of psychoanalysis and, as Erikson seems to say, are readily available to clinical investigation without it.
An authoritative study of personality development in college students has identified the four factors that most frequently cause conflict during adolescence (Report No. 32 of the Group for the Advancement of Psychiatry, 1955);
Dependence-independence. Erikson says that college education fosters “extended childishness” by encouraging dependency. He calls college a “psychosocial moratorium” that postpones adulthood and prolongs adolescence. Dependency may be manifested either by submissiveness and compliance, or by rebellious behavior brought on by the resentment of dependency. A young person’s need to show himself capable of independent decision and action may stimulate all kinds of defiance and insurgence.
Love and hostility. Home and family relationships during early years are believed to determine the adolescent’s capacity to give and accept love. The amount of resentment and hostility he experienced in childhood may determine how much of this he feels in adolescence.
Sexuality. Sexual feeling and drive are prominent in adolescence and are often poorly understood and restrained. Crumbling standards of morality, with confusion among adults as to what the standards ought to be, leave the adolescent puzzled at a time when he most needs help in controlling and directing his sexual urges.
Development of value standards. When a young person goes to college, he is likely to carry with him the value system he has acquired in home and church. As ideological ferment occurs, he will probably modify or discard these childhood values, especially when they are challenged by new ideas and authority figures. Science and philosophy are usually blamed for this shift in values, often correctly described as “loss of faith.”
Besides these four frequent causes of conflict there is a fifth, the choice of a vocation. Superimposed upon the patterns already imprinted in the home are external pressures that cause conflict in this choice. The complexity of today’s vocational possibilities, in contrast to the apprenticeship system of a generation or two ago, heightens the difficulty of selection.
The university student, standing at the threshold of young adulthood, embodies in some degree all these conflicts. They all are included in the broad concept of identity crisis.
Varieties of Adolescent Psychopathology
For some late adolescents this transition may produce anxiety or depression, perhaps with impairment of interpersonal relations. Persons displaying this group of symptoms are likely to be diagnosed as psychoneurotic. For others, the transition into adulthood may be delayed as they cling to childhood reaction patterns in adult situations. This group is likely to be classified as manifesting personality disorder. These two categories include the great bulk of psychiatric problems in the adolescent, according to an analysis of nearly 4,000 late adolescents who sought psychiatric help in the mental health service of a Midwestern university over an eight-year period. Nearly half of the students asked for psychiatric consultation on their own initiative; another third were referred by university physicians.
Psychosis, the most serious form of mental illness, in which there is some loss of contact with reality, was uncommon, making up only 6 per cent of the total. Psychophysiologic disorders, more popularly known as “psychosomatic,” were diagnosed in 7 per cent. A third category, transient situational disorder, accounted for an additional 18 per cent. This diagnosis is applied when the stress of external conditions produces maladjustive symptoms. Its use implies that the symptoms are expected to recede or disappear when the stress diminishes. These three less common conditions accounted for 31 per cent of the series. The remaining 69 per cent was divided almost equally between personality disorder and psychoneurosis.
Personality disorders, 35 per cent of the total, make up a broad category signifying immaturity in the life pattern. The distinguishing mark is some attitude or behavior inappropriate to adult life, traceable to faulty relationships during the development of the person. Anxiety or depression may be present as a by-product of the basic maladjustment.
Psychoneurotic disorders were second in frequency, making up 34 per cent of the total. The distinguishing mark in this category is the predominance of anxiety or of some equivalent of anxiety, such as conversion reaction, in which anxiety has been “converted” into a physical symptom. Anxiety is a kind of psychic alarm reaction that signals the presence of conflict or maladjustment in personality, the exact nature of which is concealed from the sufferer himself. The anxiety may be minor, or it may be strong enough to disturb interpersonal relations or impair productivity.
Discovering the cause of a psychiatric disorder may require persistent search, for the cause is sometimes unrecognized by the person himself. Therefore, the psychiatrist pursues exploratory inquiry from his earliest contact with the patient and records all data that may contribute to an understanding of the problem.
The process of understanding is made more difficult by the fact that the same symptom may have varying significance in different persons. Scholastic underachievement may express resentment toward a parent in one student and a sense of futility in another. Depression may signify either the loss of a loved object or a sense of guilt. The psychiatrist’s task is to discover for each patient the meaning of a particular symptom by studying it in its context and in its combinations.
When the broad category of personality disorder is subdivided, two variants are found to account for almost the entire group. These are the passive-aggressive type and the passive-dependent type, roughly equal in number.
Passive-aggressive personality is diagnosed when latent hostility or resentment is being expressed in passive ways, such as by obstructive neglect, idleness, procrastination, or pouting, rather than overtly. The term “personality” signifies that in the course of the individual’s life history this reaction pattern has become a habitual way of meeting everyday problems and relationships. Passive-dependent personality is diagnosed in persons who find it difficult to assume responsibility or to make decisions, preferring to lean upon or cling to other persons.
What findings led to the diagnosis of fixed immaturity in these students? Nearly half were in running conflict with their parents. Nearly half were in academic difficulty. Over half showed excessive dependency. These primary maladjustments were accompanied by anxiety or depression in a large proportion.
While aggressiveness and dependency are quite different in their external manifestations, the two conditions often have a common origin. The person who is dependent upon others usually resents his inability to stand alone, and his resentment is especially strong toward those who are responsible for his dependency. Hence, angry and aggressive feelings can often be traced to an underlying dependency. This may be caused by overprotection in the home, where parents fail to relinquish control to encourage the development of self-reliance and autonomy, or where a child is kept dependent to satisfy the emotional needs of a parent.
The dependent student may react to separation from home by frantic efforts to maintain the relationship, or he may establish new dependency relationships with the persons around him to take the place of the old. Much academic underachievement is the expression of resentment toward parents, and may result in sabotage of a given program when the student is dropped from the university. A student may work hard in a course he likes and “goof off” in others he is being pushed to take. The son of a physician, who was being prodded into following his father’s vocation, failed all his science courses but was superior in his chosen subjects, philosophy and French horn.
Leaving the parental roof has an emotional counterpart in graduation from college. The same inclination to cling and to postpone separation, the same lack of self-confidence for independent action, are seen every year in the clutch of anxiety symptoms known to university psychiatrists as “senior syndrome.”
Other immature personality types were found in smaller numbers, such as the socially withdrawn, the emotionally unstable, and the sociopath. However, the majority of the personality disorders making up 35 per cent of all patients were passive-aggressive and passive-dependent types, usually traceable to early defective relationships in the home.
Causes of Psychoneurosis
Of the 34 per cent of students who were diagnosed as psychoneurotic, a sampling showed more than two-thirds manifesting anxiety, the alarm reaction that signifies some inner conflict or maladjustment. What were the causes underlying the symptom? More than a third expressed conflict in values, lack of meaning, or concern over religion. A similar number expressed sexual guilt. These two underlying causes stand out as the basis for much of the neurotic anxiety: guilt and existential concern. Both are a notable expression of the broad conflict in values that is such an important part of the identity crisis.
Time magazine’s description of the current decade as “an era in which morals are widely held to be both private and relative … in which self-denial is increasingly seen as foolishness rather than virtue” (January 24, 1964) applies to many on the university campus. Students have insisted upon greater freedom of housing arrangements and night hours, and they have gained widespread modification of traditional rules. A recent examination of the problem comments: “Current experience on the campus … indicates that. sexual activity has become almost as common among girls as boys as postponement of sexual activity until marriage is less pronounced. This apparent shift in feminine attitudes is one of the clearly revolutionary elements in the current sexual ‘revolution’” [Report No. 60 of the Group for the Advancement of Psychiatry, 1965, p. 25].
The campus shift toward freer sexual indulgence reflects the moral laxity in society. If conscience is socially derived, the relaxing of social sanctions against premarital sexual freedom should relieve young people of their guilt. This survey shows, however, that many adolescent patients have some sense of guilt about sex. The prevalence of guilt in the midst of today’s widespread permissiveness argues anew for the biblical idea that every person has an innate sense of oughtness that will not be silenced. Anxiety and guilt signal emotional conflict. As Paul Meehl has put it, “The phenomenal experience and the associated behavior dispositions called ‘anxiety’ (of which guilt is a special sub-case) would not exist if man were in proper relationship to God” (What, Then, Is Man? [Concordia, 1958], p. 217).
The Christian concept of agape has been appropriated and perverted, not only to describe the work of the psychotherapist, but also to serve the new morality as a kind of ethical touchstone to supplant biblical standards of morality. Nevertheless, violation of conscience continues to exact its toll as guilt, anxiety, and emotional conflict follow illicit sex.
The idea that guilt is responsible for much neurotic anxiety is almost as old as the concept of neurosis itself. Stekel, one of Freud’s inner circle, described neurosis as “the disease of bad conscience.” Freud’s pupil, the Protestant clergyman Oskar Pfister, believed that all neuroses can be traced to moral conflict. Putnam, Freud’s influential advocate at Harvard, maintained that neurotic conflict is basically ethical in nature. More recently, Rudolf Allers wrote, “I pointed out as far back as 1929 that ‘at the bottom of every neurosis there is a metaphysical problem.’ ” The efficacy of religious faith in the resolution of guilt was obliquely acknowledged by Freud in 1909 when, in writing to Pfister, he recorded the observation that “religious piety stifles neurosis.”
Existential Concern
Students with emotional difficulty frequently show existential concern. Eleven in a sample of 100 were preoccupied with death. Others were deeply concerned over religion. The following comments quoted from student records are typical:
What is the purpose of existence?
What do I want out of life?
I have no long-range goals in life.
I am not doing anything worthwhile.
I am empty and rootless, without purpose.
I do not know what I am living for.
My religion has begun to seem meaningless.
I do not believe the dogma of my church.
I have given up my religious faith after a psychological discussion.
These existential concerns focus upon the most important aspect of the identity crisis: the would-be adult’s confrontation with the question of ultimate meaning. This question qualifies and transcends all lesser questions. Without some coherent world view into which all proximate issues can be fitted, the major source of anxiety remains.
B. Bettelheim well describes the quest: “They are in a great hurry to get started toward their goal; but this goal is elusive, and so they are people lost in their search, so lost that they no longer know which direction to take. Worse, they doubt that there is any direction. Therefore, their search for only an unknown goal becomes empty roaming. As long as they are on their way, they feel alive. If they stop, they fear to die. Therefore, any and all kinds of spurious activities will do, to keep from recognizing how lost they are” [Youth: Challenge and Charge, ed. by E. Erikson (Basic Books, 1961), p. 79].
What Philosophy of Life?
Religious faith has long provided such a basis for faith and commitment. The Judeo-Christian heritage has served as a foundation for what Parsons has described as “the conception of man’s role as an instrument of the divine will in building a kingdom of God on earth.… the building of the ‘good life,’ not only for the particular individual but also for all mankind” (ibid., p. 97).
Freud chose to adopt the position of Feuerbach—that is, that God is only the product of wishful thinking—and aligned himself with Comtean positivism. Erikson has followed closely. “Man’s creation of all-caring gods is not only an expression of his persisting infantile need for being taken care of, but also a projection onto a superhuman agency of an ego ideal” [Insight and Responsibility (Norton, 1964), p. 132].
Farther on, he agrees with the idea that “religion exploits, for the sake of its own political establishment, the most infantile strivings in man.” While he repeatedly affirms the importance for the adolescent of “the fervent quest for a sure meaning in individual life history and in collective history,” Erikson discredits religion and rejects its contribution to a coherent world view. Thus, even as he deplores the “acute lack in ideological nourishment during adolescence,” he pledges allegiance to naturalism and arbitrarily eliminates alternative philosophical options.
This is a too easy disposition of the mature record of human religious experience, and it suggests that naturalism itself may be one of the “rationalizations and repressions of changing civilizations” Erikson describes. As Pfister recognized in “Illusion of a Future,” the affirmation of faith in science may itself be underlaid by a process of wishful thinking.
The widespread repudiation of the transempirical in our time tends to produce an ideological vacuum. Many university students surrender faith in transcendental reality under the pressure of naturalistic or positivistic views. A few “cop out,” to abandon the conventions of society for the immediate gratifications of sensual experience, new as well as old. Adolescent rejection of conformity only produces a new variety of peer conformity.
Many students are seeking a cause that merits their commitment. The success of such projects as the Peace Corps points to the vast backlog of devotion and loyalty among young adults that awaits challenge. Today’s disparagement of Christian faith and commitment often shatters vocational purpose and alienates the loyalty of students.
Sir Walter Moberly indicts the university for betraying the student by failing to help him formulate a working philosophy of life: “Some sort of embryo of a working creed he must have; no one out of an asylum can live without it. But his version is uncritical and mainly unconscious, it is picked up at haphazard, and it is muddled and incoherent” [The Crisis in the University (Student Christian Movement Press, 1949), p. 61].
By leaving God out, Moberly says, we have taught with tremendous force that he does not count. Alexander makes a similar charge:”It is not only that extreme specialization threatens the cohesion of the university as a community of scholars, but it finds itself straightly charged with failing to provide those under its tutelage with the ingredients of valid decision, far less a coherent ‘philosophy of life’” [Faith and Learning (Association, 1960), p. 29].
These criticisms strike hard at two features of the contemporary university order: (1) the exaltation of a spurious objectivity, and (2) the tendency to eliminate religion as an optional curricular resource.
Speaking of the first, Moberly declares:”so-called academic objectivity is a fraud; and the fraud is none the less disastrous and reprehensible because its perpetrators are commonly also its victims and deceive themselves as successfully as they deceive others” [Moberly, op. cit., p. 59].
The psychiatrist as well as the professor respects neutrality. He knows that it is important to free his patients for autonomous choice while he is helping them recognize their own neurotic distortion and compulsion. Ideally, therefore, he tries to hold in check his own inclination to indoctrinate, whether he is on the side of Christianity or of atheism. What is ideal for the psychiatrist is no less ideal for the professor; the shelter of the classroom and the immunity of academic freedom ought not to be misappropriated to allow doctrinaire force-feeding. Yet, even when the psychiatrist and the professor punctiliously refrain from indoctrination, they still subtly convey their own life philosophies to those under their influence. They cannot be wholly neutral in these relations any more than in their own minute-to-minute life choices.
An empirically based psychiatry can help the student understand why he is anxious, but the philosophical context will inevitably be colored by the psychiatrist’s own world view. The professor can set in order and perspective the data of his discipline; in so doing, however, he reveals his own philosophy. The student’s mind cannot remain long in an “open” position, where ultimate decisions are indefinitely postponed in a posture of “objectivity.” Anxiety occurs not only when new value systems are offered in place of old but also during the time that choices are delayed. Ultimate questions of life philosophy are linked to urgent practical questions that demand answers.
As the efforts of the conscientious psychiatrist or professor to maintain a neutral stance are limited by the inevitable obtrusion of each one’s personal philosophy, so the university’s claim to neutrality is similarly qualified. The university is an assemblage of committed persons, each of whom has given homage to this or that metaphysical system. As each man’s neutrality is relative, so also is that of the university. Its professed openness in the quest for truth is qualified by the commitments of its constituent individuals, who have made affirmations of faith to a variety of gods.
The Church’s voice should be clearly heard in this cacophony of commitments. As Christian theology competes for a hearing in the ideological market place, it lacks the burgeoning prestige of science and may have shabby treatment at the professorial rostrum. Still, its doctrine of man has impressive maturity and far-reaching support. The system of values mediated by the Church not only illuminates the complex problems of man’s existence but also offers forgiveness for guilt and meaning for life. It is the antidote for much of man’s anxiety.
