The Shape of the Thought: Listening for Structure in Unwanted Intrusive Presentations

An interactive UITS seminar with Dr. Harris and Dr. Lewton

What follows is a fictitious but clinically grounded seminar that explores how therapists can learn to listen not just to what is being said, but to the structure and form of speech in adolescents struggling with unwanted intrusive thoughts.

Rather than composing a traditional academic or theoretical paper on the subject—which was certainly tempting—I chose to present this material as a scripted seminar, combining clinical depth with aesthetic engagement. The result, I hope, is both illuminating and enjoyable: a space where psychoanalytic ideas, countertransference dilemmas, and practical verbatim responses are brought to life through dialogue, curiosity, and shared inquiry.

This is a seminar about listening. Not just for symptom, but for structure. For rhythm. For psychic manoeuvre. For the architecture of how a mind tries to survive its own contents.

Dr. Harris and Dr. Lewton guide the room with thoughtfulness and clinical precision. Participants question, challenge, and deepen the conversation. What emerges is not a technique—but a way of thinking, a way of being with young people whose thoughts feel unthinkable, and whose speech often holds more than it seems.

The room is full. A quiet hum of anticipation settles over the group as chairs are drawn into a loose, egalitarian circle. There’s a comfortable mix of experience in the room—veteran clinicians, familiar with the long arc of psychodynamic work, and newly qualified psychologists and psychotherapists, keen-eyed and curious. Coffee cups sit on the floor beside notepads already dotted with scribbles.

Setting the scene

At the centre of the circle, Dr. Harris and Dr. Lewton are seated—not apart from the group, but with them. Calm, attentive, and unhurried. There is no podium. No PowerPoint. Just conversation.

There’s an air of seriousness and excitement—the feeling that something matters here. These clinicians haven’t come for quick strategies or solutions. They’ve come to explore something more subtle: how to listen more deeply to the shape and structure of what children and adolescents say when they’re haunted by unwanted intrusive thoughts.

It is not a seminar about technique. It is a seminar about tone. Containment. And above all, how to hear the inner architecture of a mind in distress.

Dr. Harris:

Welcome to the first in a three-part UITS seminar series on deep listening. Across these sessions, we will learn to listen not for diagnosis, not for protocol—but for psychic structure. For the shape of suffering. For how the mind speaks when it is afraid to speak plainly.

This first seminar focuses on intrusive thoughts and the various psychic structures that shape how they are presented in the room.

Dr. Harris:

Let’s begin with something deceptively simple: not what the adolescent says, but how they say it. Not the content—but the structure. The form of their speech. The rhythm. The breaks. The texture.

Because unwanted intrusive thoughts do not float in from nowhere. They are shaped by the mind that produces them—and they reveal, in their very form, the psychic function they serve.

Dr. Lewton:

For the non-psychoanalytic clinical psychologists and therapists—this is a very psychoanalytic idea. It’s not about symptoms as isolated things (e.g., “they’re anxious” or “they have OCD”, “they’ve got depression”) but about how the unconscious layer of the mind is working—what tactics and ways of managing is it using to deal with inner conflict, trauma, stress or emotional overwhelm.

Think of a defence mechanism like a chess move you observe when watching your opponent. You can’t just look at the piece that moved (content)—you have to understand the player’s strategy. Is this a sacrifice? A trap? A retreat? Progress? (Structure).

So, with that analogy fresh in your mind, the structure of the adolescent’s speech might show you their strategy—how their unconscious is manoeuvring to avoid pain, control anxiety, or manage desire.

Dr. Harris:

Yes, well explained Dr. Lewton. That is the heart and soul of all therapy—curiosity. Seeing beyond what is presented to you.

So today, we are not listening for symptom. We are listening for structure. For psychic manoeuvre. For what Meltzer might call the “architectural configuration of the internal world.”

Dr. Lewton:

I would probably just introject here one more time and link this way of listening to when we think about music. The lyrics (what is said) tell a story. But the melody, rhythm, and tone (how it’s said) give you the feeling—a whole other layer of meaning. You might hear sadness not in the words, but in the slow tempo, halting rhythm, or monotone voice.

In speech, similar things happen: pauses, repetitions, shifts in tone, or sentence structure can carry unconscious material that isn’t directly accessible through content.

It may also be worth saying for those who are unfamiliar with both Wilfred Bion and Donald Meltzer. Wilfred Bion and Donald Meltzer were psychoanalysts interested in how the shape of the inner world affects a person’s experience. Meltzer thought of the mind almost like an architectural space—with rooms, walls, divisions, pathways. Some minds are open, integrated. Others are fragmented, collapsed, labyrinthine.

So when Dr. Harris talks about listening for the “architectural configuration” of the mind, I think what he means—and jump in if I’m off here, Dr. Harris—is that we’re listening for the shape of the thinking, not just the content. Like, are there sharp breaks in the flow of thought—does it feel like something’s been split off or walled away? Or do you hear the person going in circles, stuck in a kind of psychic cul-de-sac? Sometimes there’s this rigid, tightly structured language that tells you everything is being kept in perfect order—maybe to stop something messier from slipping through.

Or maybe you notice what’s not being talked about—like there’s a part of the mind that’s off-limits, a room we’re not allowed into. And that avoidance itself tells us something about how the internal space is organised. So it’s not just what they’re saying—it’s how the whole system is built to protect, contain, or sometimes hide certain parts of the self.

Participant (P14):

Okay—I do find that really interesting, especially the architectural image. It’s compelling.

But what does that actually look like in the room? Like, what are we really seeing or hearing when we say a mind is fragmented or stuck in a loop, or avoiding certain rooms, or overly rigid? What do we do with that kind of observation? What does it tell us? Because I hear the metaphor, but I’m trying to picture what it actually says about the person sitting in front of us.

Dr. Lewton (responding):

Yes—I really appreciate that question. And you’re absolutely right to pull us back to what this actually looks and feels like in the room. Metaphors like architecture are useful—but only if we can translate them into clinical observation. Otherwise, they’re just elegant language floating above the work.

So let’s slow it down and think together. Imagine you’re sitting across from a young person. They’re speaking, and you notice that every time the conversation gets near a particular topic—maybe something emotionally loaded, like a memory of humiliation or something about their father—they suddenly divert. The speech loops, gets vague, or changes subject. That’s not accidental. That’s not conversational style. That’s structure. That’s the internal world saying, “You’re not allowed in that room.” It might be defended against through avoidance, through dissociation, through control—but what you’re hearing is that there’s a space inside them that’s too charged to access.

Or let’s say they’re describing deeply distressing events with mechanical precision. Everything’s crisp, factual, emotionally scrubbed. That, too, is meaningful. It tells us we’re in a mind that’s holding itself together through rigidity. The walls are thick. The doors are locked. That can be a trauma response, or it can reflect a personality style that leans heavily on control to stay safe.

On the other hand, you might have someone who speaks in loops. They return to the same idea again and again—going round and round without moving forward. That tells us something too. They may be trapped inside an internal cul-de-sac—thinking as a way to avoid feeling, or repeating because the affect underneath hasn’t yet found language. That’s not just a style of speaking—it’s an echo of the internal world struggling to metabolise something.

And sometimes, of course, there’s fragmentation. Speech that breaks apart. Thoughts that won’t link. You’re not hearing a story; you’re hearing raw material—affect leaking out without the scaffolding to hold it. And that might suggest that the internal architecture has buckled under pressure, or that the adolescent never had the materials to build symbolic thought in the first place.

Now, what do we do with this? We don’t interpret immediately. We don’t pathologise. But we notice. We begin to sketch—not diagnose, but sketch—a sense of how this person organises experience. Where the load-bearing walls are. Where the access points are blocked. We begin to form a feel for the structure of their psychic house—not just its furniture.

So yes, the metaphor is poetic. But it’s also deeply clinical. Because once you know the shape of a mind, you can begin to move through it more safely, more gently. And that’s what this kind of listening allows. Not just hearing what is said—but understanding how a person is managing to say anything at all.

Dr. Harris:

Exactly. What I want to do now is take us into four clinical examples—each illustrating a different mode of thought presentation. But I want you to listen not just to what is said, but to the quality of the saying. The texture. The rhythm. The psychic shape that underlies the language.

Now, as therapists, we are often quite adept at hearing tone and affect. That’s a baseline skill—picking up on shifts in mood, listening for what’s emotionally congruent or incongruent. For example, we know instinctively that “I’m fine” can mean radically different things depending on whether it’s said with a shrug, a glare, or through clenched teeth. That kind of emotional decoding is something we do intuitively, and fairly objectively.

But what we are focusing on in this seminar—and in future ones—is something even deeper. We’re not just listening for mood. We’re listening for structure. We’re listening for the architecture of the speech—its organization, its fluidity or rigidity, its rhythm, its breaks. Because the way the adolescent speaks often tells us how their mind is functioning in that moment. Is it integrating or evacuating? Is it symbolizing or disavowing? Is it inviting relationship, or holding it at arm’s length?

So we are not looking for metaphorical flourishes or over-interpretation. We are listening to form as clinical data. Thought has a structure, and when that structure shifts—fragments, flattens, tightens, rehearses—it tells us about the emotional manoeuvres at play beneath the content.

Participant (P3):

But aren’t we in danger then of making assumptions based on theory? Or worse, not appreciating the way someone talks more generally—how they were raised, their culture, their personality? Isn’t the danger here that we start over-analysing everything, seeing pathology where there might just be personal style?

Dr. Harris (responding):

An important challenge—and a necessary one. And you’re quite right to raise it.

Yes, there is always a danger in clinical work of over-reaching—of hearing through the filter of theory rather than with the openness of presence. If we go in looking for pathology, we may find it everywhere. So we have to tread very carefully. Theory should never be imposed onto the patient—it should arise from our careful, sustained attention to the material.

So how do we guard against over-interpretation?

We stay curious. We stay provisional. We ask ourselves not “What does this mean?” but “What might this be doing psychically?” We hold theory as a hypothesis, not a conclusion.

And importantly, we listen with cultural humility. We ask: Is this mode of speech part of this person’s relational style? Their community? Their neurodiversity? Their sense of self? We don’t assume—we inquire, internally and, when appropriate, collaboratively.

But we also don’t retreat from listening deeply. The risk of over-interpreting is real—but so is the risk of under-hearing—of failing to notice when someone is drowning in affect, collapsing under control, or hiding behind rehearsed shame.

So our task is to hold both: clinical rigour and emotional humility. We listen with theory in one hand, and human intuition in the other. And if we find ourselves certain, we ask again.

That’s not over-analysis. That’s disciplined empathy.

Dr. Lewton (adding):

Yes, I’d just add—sometimes we do assume we’re just hearing someone’s relational style: “Oh, they’re just very rational,” or “She’s always flat like that,” or “He just talks that way.” And yes, sometimes that is temperament or context.

But I think when the material shifts—when it’s about something distressing, like an intrusive thought—that’s when we start to get more clues. Because that content puts pressure on the system. And the way they communicate under pressure can tell us something about the internal world. Do they tighten? Do they fragment? Do they disavow?

So it’s not about pinning a personality label on them—it’s about seeing what changes in the speech when emotion enters the room. That’s where the structure shows itself. And that’s often where we get the most meaningful access to what’s happening psychically. Not in the content alone, but in the way the content is delivered.

Participant (P5):

Sorry—I’m quite new to all of this. When you say psychic structure, what exactly do you mean? Is that the same thing as personality structure?

Dr. Harris (responding):

Great question—and I’m glad you asked it, because this is one of those phrases we all throw around, but it can sound a bit mysterious if you’re not steeped in the language.

So—psychic structure is not quite the same as personality in the everyday sense. When we talk about personality, we’re often referring to traits: introverted or extroverted, agreeable or assertive. That’s the external presentation.

But psychic structure refers to something deeper—it’s about how the mind is organised, especially under stress. It’s the underlying architecture that determines how someone processes emotion, handles conflict, defends against anxiety, and maintains a sense of self in relation to others.

To use an analogy: personality is the house’s decor—what colours are on the walls, how the furniture is arranged. Psychic structure is the framework—where the load-bearing walls are, how the wiring works, what happens when there’s a storm. Some houses bend and flex. Others crack. That’s structure.

So when we listen to speech—especially in the context of distressing material like intrusive thoughts—we’re not just hearing what someone thinks, or how they feel. We’re hearing how their mind is managing internal pressure. And that tells us something about their structure.

Some adolescents fragment. Some flatten. Some intellectualise. Some attack themselves. And each of those modes of thought reflects a different way their mind has learned to stay intact.

Does that help clarify it?

Participant (P5)

Thank you. That is actally really clear and makes a lot of sense now. I guess it also highlights how we can capture to some extent personality structure with self-report measures and measures to see how people cope with stress but I guess being in a room with them in more of an 'alive' way would actually help you see a different part of them that cannot being captured by psychometric measures.

1. Fragmented – Discharge of Raw Affect

Dr Harris: Let’s begin with what is often the most viscerally arresting form of presentation—what we might call fragmented speech, where thought doesn’t so much arrive as erupt. In these moments, we’re not listening to someone telling us about an experience—they’re in it, inside it, often without any symbolic distance. The adolescent’s language is fractured, breathless, rushed—there’s a collapse in grammar, time, and coherence. We are not in the realm of narrative. We are in the realm of discharge.

These are not symbolic thoughts. They are raw affective fragments—what Bion would call beta elements—flashes of sensory and emotional material that have not yet been metabolised into meaning. They come out not because the young person wants to explore them, but because they cannot bear to hold them any longer.

Let’s listen to a few examples—not just for what is being said, but for how the form of the speech tells us something about the psychic state underneath.

“I don’t know—I just—I saw his face and then I—knife—like, I didn’t mean to—like in my mind—I just wanted to make it stop—my head—everything—”

"It just—I saw my sister and—thoughts—hands on her neck—no, never—but it came, flashes—my heart, racing, like—like losing it—stop—stop—”

“I touched the handle and—it hit me—dirty, disgusting—wrong—like my skin crawling—can’t get clean, get off me—why—why—”

"Church and then—God, horrible—I saw, images—curse words, shouting in my head—God hates me—sin, burning, help—I didn’t mean—please—stop—”

Dr. Harris:

This is not speech—it’s an explosion. The grammar collapses. Time dissolves. We’re in the territory of beta elements—undigested, unprocessed fragments of terror.

Dr Lewton:

I agree. So,even beyond unwanted intrusive thoughts as the original concern- some of the most unwell adolescents we all work with have this speech pattern. When we listen and look at this in any clinical context, there is no stable I in this narrative—no coherent subject telling a story about a past event. Instead, we’re in the middle of an emotional detonation.  I often describe this as “fragmented speech” in my clinical case notes - but fragmented speech is more than just a description it’s a signal about an individuals current psychic function.

Dr Harris:

Psychic function? Discharge. The thought is not symbolic yet. It is affect being expelled—projected—because it cannot be borne.

Participant (P8):

I’m sorry—I need to pause you for a second. I think I’m getting a bit lost in the language here.

You said, “Psychic function? Discharge. The thought is not symbolic yet. It is affect being expelled—projected—because it cannot be borne.”

Okay… I’m going to try to say this in my own words—and you can tell me if I’m even close.

It sounds like what you’re saying is: the young person is completely overwhelmed with a feeling—like a panic or a dread—that they don’t really understand, and can’t name. But it’s so intense, their mind just has to get rid of it somehow. So it comes out in this raw, unfiltered way. Not a proper thought. More like a blast of emotional noise. And their ‘psychic’—or I’d just say their ego, or sense of self—can’t hold it, so it throws it out.

Is that kind of what you’re saying?

Dr. Harris (responding):

Yes—beautifully put. That is exactly the spirit of what I’m saying.

And I really appreciate you stopping us to slow it down—because these terms can sound abstract if we don’t ground them in real emotional experience.

When we say “psychic function”, we’re just asking: What job is this thought doing inside the mind? Not what does the thought say on the surface—but what function is it serving emotionally?

In this case, as you said, the function is discharge. The mind is overwhelmed. It’s holding something it cannot tolerate—maybe panic, maybe terror, maybe unbearable shame. And because it hasn’t been processed, the mind can’t think it, can’t name it, can’t symbolise it. So it does the only thing it can do: it expels it.

Not with words that make sense. Not with a tidy narrative. But with a psychic blast—speech that sounds more like a seizure than a sentence. The goal isn’t communication—it’s evacuation.

Now, you used the word “ego,” and that’s helpful. In classical terms, the ego’s job is to mediate between inner chaos and external reality—to hold things together. But in this moment, the ego is flooded. So the unprocessed affect spills out through the only route available: speech. But it's not speech as meaning—it’s speech as pressure release.

So yes: overwhelmed, unintelligible, and not-yet-symbolic. That’s what we’re listening to. And when we hear that, our task is not to interpret—but to contain. To help the mind begin to digest what, so far, it has only been able to expel.

Dr Lewton:

The adolescents intrusive thoughts are not communicating. It’s not processing. It’s discharging—evacuating unbearable inner states by hurling them out into the world. They just so happen to land in the receptive mind of the clinician seeing this young person.

Participant (P9):

Sorry—just in the spirit of slowing things down again. I think I’m following bits of this, but I’m not totally clear on what Dr. Lewton just said.

You said the adolescent’s intrusive thoughts aren’t communicating—they’re discharging. And I think that echoes what Dr. Harris said earlier, but I’m still a little lost.

So let’s say we get a referral: “Young man struggling with distressing intrusive thoughts.” He turns up, and at some point produces this fragmented, scrambled kind of speech.

What exactly are we saying the intrusive thoughts are doing at that point? Like—you’re saying they’re not communicating what, exactly? Not communicating meaning? Not communicating distress? Or that they aren’t meant to be communicative at all?

Sorry if I’m splitting hairs—I just want to be really clear on what we’re hearing in that moment.

Dr. Lewton (responding):

No—that’s not splitting hairs at all. That’s an excellent clarification to ask for, and I’m glad you did.

So let me slow it right down and put it like this:

Normally, when we think of a person talking to us—even about something painful—we imagine they’re trying to convey meaning. They’re using words to describe, to process, to communicate something about their experience—“This is what I felt,” “This is what happened.”

But in the kind of fragmented speech we’re talking about—when someone is deeply overwhelmed—the words aren’t being used like that. The adolescent isn’t describing their experience. They’re having it, in real time, in front of us. The speech is not narrative—it’s symptomatic. It's not an attempt to tell us something. It's an attempt to get something out.

So when I said “it’s not communicating,” what I meant is: it’s not symbolic communication. The thought isn’t being used to express an idea or invite understanding. It’s more like a pressure valve. The speech is affect-laden, chaotic, almost physical in its urgency. It’s a discharge—not a conversation.

So yes—in that moment, what we can deduce, as you say, is that the intrusive thoughts are not being metabolised. They haven’t been thought about—they are being evacuated, because the system can’t contain them. It’s like the mind is throwing something unbearable out into the room. And we, as clinicians, just happen to be the container it lands in.

And this is why the clinician’s presence matters so much. Because we don’t just analyse the content—we receive the communication the mind itself can’t bear to know it’s making.

So in short: the thoughts aren’t communicating ideas—they’re expressing states. And our task is to help the adolescent gradually move from evacuation to symbolisation. From unthinkable affect to thinkable thought.

Participant (P10):

If I can just say—I’ve definitely encountered this kind of fragmented speech in some young people, particularly when they’re very anxious or under pressure. But honestly, I’d say it’s rare. Most of the adolescents I see with OCD talk in a much more controlled or rehearsed way. The only time I’ve really seen this level of fragmentation is in cases where there’s psychosis or something close to it.

Dr. Harris (responding):

Yes—that’s a very common and understandable observation, and I think it points to something we need to be careful and precise about.

You’re right that this kind of highly fragmented, disorganised speech is often associated with psychosis. But we have to differentiate between formal thought disorder—which is a diagnostic indicator of psychosis—and what we’re calling here a momentary collapse in symbolic capacity.

The fragmentation we’re talking about in this context isn’t the kind that persists across all domains of functioning. It’s state-dependent, affect-driven, and often transient. It shows up when the adolescent is flooded with unprocessed affect—terror, shame, helplessness—and their usual defences fail them.

So yes, the adolescent with OCD may typically speak in a controlled or ritualised way. But if something pushes them beyond their threshold—if the intrusive thought becomes fused with panic or unbearable guilt—you may suddenly see that careful structure break down. Not because they’re psychotic, but because in that moment, the ego is overwhelmed.

And that’s important clinically—because if we only associate fragmentation with psychosis, we’ll miss these moments of psychic decompensation in neurotic or obsessional structures. We’ll misread the panic as disorder, rather than as a moment of structural collapse under pressure.

So yes, it’s less common—but not at all exclusive to psychosis. And when it appears, even briefly, it tells us a great deal about the adolescent’s capacity to mentalize distress, and what kind of containing function they might need from us.

Participant (P11):

Ah, I see—that makes a lot of sense. I suppose I just haven’t encountered that kind of speech very often in the young people I work with.

But I want to ask something maybe a bit geeky. We keep using the word “fragmented.” And I get the general idea—it’s speech that’s disorganised or chaotic. But if we were going to get a bit more technical about it—without straying too far from the focus on intrusive thoughts—what exactly defines fragmented speech? Like, what are we actually listening for?

I do think therapy is an art—but it’s a science too, right?

Dr. Harris (responding):

Yes—wonderfully put. Therapy really is both an art and a science, and your question gets right to the heart of that tension. If we’re going to call something “fragmented speech,” we do need to be clear about what we’re actually hearing—not just in a poetic sense, but in terms of the underlying structure of the language.

So let’s get a little more specific. When we use the word fragmented in this context, we’re referring to a breakdown in the usual coherence of thought and language. Speech, under normal conditions, has a rhythm, a structure—it moves through time, it holds together. Even if it’s emotionally charged, there’s usually a kind of narrative spine holding it upright: things happen in order, thoughts follow from one another, syntax holds. But in fragmented speech, that scaffolding gives way. We hear thoughts that trail off mid-sentence, or restart suddenly. Sentences are chopped up, syntactically incomplete. It’s often very hard to locate when something happened—there’s a confusion of past and present, or an eternal now that feels frozen in trauma.

Sometimes the adolescent jumps from one idea to another with no apparent link. But it’s not random—it’s affect-driven. What’s leading the speech isn’t logic, it’s emotional intensity. You can also hear particular words or images that erupt into the sentence without warning—almost like intrusions in the speech itself. It’s not just the thought that’s intrusive; the language becomes intrusive.

Now, I want to be very careful here—we’re not talking about psychosis. This isn’t formal thought disorder. This is often transient, affect-driven collapse. A moment where the adolescent’s capacity to symbolise what they’re feeling breaks down, and so the speech becomes the raw material of the distress itself.

You’re not being told about a feeling—you’re hearing the feeling in the form of language. And that’s what we mean when we say the speech is fragmented. It’s not just messy or unclear. It’s structurally disrupted, because the ego can’t hold the affect in a thinkable form.

So yes—it’s right to slow down and ask what we’re hearing. And I think what we find is that even in the most chaotic speech, there is form. And if we can learn to listen to that form—if we can see the pattern inside the collapse—we can begin to think with the adolescent about something they, so far, can only expel.

Participant (P12):

I think this type of fragmented speech seems quite unusual in OCD—at least in my experience. I haven’t often heard it like that.

But I will say… I’ve definitely had parents describe something close to it. They’ll say their adolescent was absolutely fine and chatty one minute, and then later that day, “they weren’t making any sense.” The parent might use words like “bizarre” or say the speech was incomplete, or they were jumping around.

So maybe we don’t always hear it in the therapy room—but it’s happening. And actually, I wonder if sometimes the young person becomes less fragmented with us because they’re in a space that specialises in OCD. Maybe just being in that setting takes the edge off. Whereas at home, alone in their room at 11pm, that’s when it gets too much.

Dr. Lewton (responding):

Yes—I really appreciate that, and I think you’re speaking to something very important: the difference between what the adolescent shows us, and what they’re actually living.

We sometimes forget that what we see in clinic is often a regulated version of their distress. They may have spent the whole day winding themselves up to come in. Or they may feel, consciously or not, that here—finally—they’re meant to have it together. And as you say, just being in a specialised OCD service may give a temporary sense of containment, a feeling that, “These people get it. I don’t need to fall apart right now.”

But at home, in the dark, at 11pm—when the distractions fade and the rituals don’t work, and the mind starts looping—that’s when the containment breaks down. And that’s often when we see, or hear second-hand, these moments of fragmentation.

So yes, even if we don’t always witness it directly, we need to hold the possibility in mind. And I think what you’re pointing to is also a reminder to listen very carefully to what parents and carers report. Not just the content—“They said something weird”—but the form: Was their speech collapsing? Were they jumping around? Did they sound frightened or disconnected from time? Because these are clues that the adolescent is hitting a point of psychic overload.

And I’ll also say this: sometimes the absence of fragmentation in the room is also meaningful. It might signal repression. It might signal over-control. Or it might be a relief response. But either way, it tells us something about the structure that’s operating when they’re with us—and what might be different when they’re not.

So thank you. That’s an important reminder to keep our clinical ears tuned not just to what we hear in session, but to what we’re told happens outside the frame. That too is part of the psychic picture.

Participant (P13):

Okay—I’m going to play devil’s advocate for a second.

Let’s say I’m with a parent, and they tell me about a moment where their child’s speech was disjointed or hard to follow. And then I ask something like, “Were they frightened? Were they collapsing psychically?” I can already hear the parent saying, “Well, maybe—but what does that mean? What are you saying is actually going on?”

Because at the end of the day, parents want clarity. They want to know what it means. And I think we do have to be careful here. We can end up over-empathising or over-interpreting something we don’t really have any technical evidence for.

Dr. Harris (responding):

Yes—thank you. That’s a very fair challenge. And I think you’re right to name the tension between clinical depth and communicable clarity, especially in our work with parents.

So let’s take this seriously. When a parent tells us their child “wasn’t making sense” or “was talking strangely,” and we begin to wonder—internally—if there was a moment of psychic fragmentation or affective flooding, we are not diagnosing in that moment. We are hypothesising. We’re orienting ourselves not around certainty, but around possibility—asking: What kind of internal experience might produce that kind of speech?

Now, you’re right—parents often want clear answers. They’re frightened. They want to know what’s happening and what they should do. And we do have a responsibility not to speculate wildly or speak in mystifying terms.

But that doesn’t mean we can’t think deeply. It means we must translate our depth into something useful.

So instead of saying, “Your child may be fragmenting psychically,” we might say something like, “It sounds like he was overwhelmed, and at that moment, words weren’t working the way they usually do. That tells us that something inside felt too big to manage, and his system didn’t quite know how to hold it.”

That’s a formulation rooted in real clinical observation. We’re not labelling—we’re reflecting.

And to your point about evidence: you’re right—we don’t have biometric proof of a psychic collapse. But we do have something else: we have the form of the communication, we have the context, and we have the pattern. Over time, those elements offer strong, if inferential, evidence about the adolescent’s emotional organisation.

Psychoanalytic thinking has always been a discipline that reads beneath the surface—not in a reckless way, but in a rigorous, relational way. So yes, we must be careful not to over-pathologise. But we must also be careful not to flatten the meaning of what we hear, simply because it’s hard to quantify.

In the end, what the parent needs from us is not a diagnosis of collapse. What they need is someone who can say, “I think something felt too much for him in that moment—and here’s how we might begin to make it feel more manageable.” That’s the bridge between our internal thinking and their lived reality.

Participant (P2)

Adolescents are an ambivalent bunch. How do we know their fragmented speech is not just nervousness, tiredness, laziness, or “can’t be bothered to speak properly”?

Dr. Harris:

A very fair challenge. The answer lies in attuning to the texture of the communication, not just the surface behavior.

Yes, adolescents often speak with reluctance, irony, or detachment—but this is performance. What we’re discussing is something else: a breakdown in the symbolic function of speech itself.

Nervousness might produce hesitations. Laziness might flatten tone or reduce vocabulary.

But true fragmentation is marked by:

Interruptions that feel involuntary, as if something floods the system mid-sentence.

Sudden bursts of affect—rage, panic, confusion—that derail grammar. Speech that sounds more like affect trying to find a form, rather than words conveying a thought.

So we must always ask: Is the breakdown in communication defensive? Strategic? Or is it structural—indicating something in the psyche is under siege?

Participant(P3)

If they initially speak in a fragmented pattern about their intrusive thoughts and then toward the end of the 50 minutes form more of a coherent narrative—does that mean their psychic function has already shifted?

Dr. Harris:

Ah, now we’re listening to process—and rightly so.

Yes: if the speech begins fragmented and then slowly coheres, we are likely witnessing the activation of alpha function in real time. Something has been contained, digested, thought.

This is a clinical transformation worth noting—but let’s be precise. The shift may be temporary—a “pocket” of thought amidst chaos. It may also be transference-based: your containing presence is metabolizing their unthinkable experience. Or it might represent a defensive manic organization—a sudden, pseudo-coherent narrative that patches over unbearable affect.

So yes, a shift in speech can indicate a shift in psychic function. But always ask: Is this narrative a symbolization? Or a simulation?

Participant (P4)

I am no expert, but I know Meltzer was heavily involved in literature and listened to sentence structure. What do you think he would be listening for to say, with some degree of confidence, that he was listening to fragmented speech?

Dr. Harris:

Excellent. Meltzer was indeed a lover of literature—and more crucially, of syntax. He believed that the form of a sentence tells us something fundamental about the form of the mind that speaks it. That is, he wasn’t just interested in what someone said, but how the sentence itself was built—what its shape could reveal about the psychic architecture beneath it.

If Meltzer were listening to a piece of fragmented speech, he wouldn’t just be hearing it as chaos or confusion. He’d be tracking very particular elements. For example, he’d be noticing the way clauses fall apart mid-sentence—how syntax loses its containment. He’d be listening for the breakdown of temporal logic: where time collapses, where there’s no clear sense of past, present, or future, only a kind of looping, collapsing now. And he’d be paying close attention to the absence of metaphor. Because metaphor isn’t just a literary flourish—it’s a sign that the mind is symbolising, that it’s able to represent something emotionally charged in a way that can be held and thought about. When metaphor is missing, Meltzer would say, we’re in the territory of something pre-symbolic.

So he might hear a fragmented sentence and say: this is not a mind using words to think—it’s a psyche trying to evacuate unbearable experience through sound. There’s no intention to communicate, only a desperate need to expel. And that tells us something profound about the emotional state of the speaker—not just that they’re upset, but that they’re on the edge of what can be thought at all.

Dr. Harris (concluding):

Let us not forget—we are not only listening to adolescents, but to states of mind that may be pre-verbal, pre-symbolic, or in the act of forming. Our task is not to correct the speech, but to metabolize the terror behind it.

Now, let’s turn to the question of how we speak back—what kind of language does not repeat the trauma, but holds it, digests it, perhaps even names it.

Dr Harris:

How do we respond to speech that is fragmented suggesting a discharge of affect. We respond by Surviving the flood.

“It feels like the thought just burst in without warning. We can slow it down together.”

You are not interpreting here. You are being a thinking container—a Bionian breast. Don’t rush to meaning. Hold.

Dr Lewton:

I think when someone is that fragmented language needs to be conscise and to the point. No interpretations. No cleverness. Just naming what you’re intuiting and feeling. Based on the example I would consider saying:

“That came out fast—like something that’s been crashing around inside you, too big to hold. We can slow it down here. There was a face… then a knife… then something in your head that needed it all to stop?”

“It’s like your mind showed you something you didn’t ask to see—and even saying it out loud feels dangerous. But maybe part of you hoped someone could hear it and not run away.”

Dr Harris:

Yes that is the way to respond. Naming what you saw and then hypothesise what may have been underneath that communication.

Participant (P4) if we assume the adolescent is experiencing their intrusive thoughts as a way that makes their mind discharge and come out in a fragmented way - what hypotheses would we potentially have about them even in this very early session - assuming the fragmented speech was consistent?

Dr Harris:

Yes—very good question. If, by the end of a first session, we’re hearing consistent fragmentation in an adolescent’s speech—especially in the context of intrusive thoughts—we can begin to formulate some early hypotheses about the psychic architecture we’re encountering. These aren’t diagnoses, of course, but working hypotheses about what the mind may be doing in order to survive.

First, we might wonder whether the adolescent’s mind is functioning under such extreme internal pressure that even the basic containment of thought has collapsed. When intrusive thoughts emerge in a fragmented burst—jagged, unsequenced, and affect-laden—it suggests that the thought has not been mentalized at all. It is being expelled rather than represented. In Bion’s terms, this would indicate a breakdown in alpha function—the mind cannot transform raw emotional data (beta elements) into symbols, into thinkable thoughts. What we’re left with is affect being discharged violently through language, not communicated with it.

More specifically, in the case of intrusive thoughts, this kind of fragmentation might suggest that the adolescent experiences the thought as foreign, invasive, or even persecutory. It doesn’t feel authored by the self. It comes crashing in from the outside—or from some sealed-off pocket within—and the psyche can do little more than vomit it up. We might then hypothesize that the adolescent is not just overwhelmed by anxiety or conflict, but that they are grappling with a more fundamental disturbance in the boundary between inside and outside, self and not-self. This could point us toward an underlying psychotic or near-psychotic structure, or at least a momentary collapse in representational thinking.

Another possibility is that these intrusive thoughts are fragments of unmentalized trauma. If the adolescent has suffered a psychic shock that could not be symbolized at the time, we often see its return in precisely this form: fragmented, image-driven, emotionally charged, and temporally confused. The speech is not narrative—it’s flashback. Not remembered, but relived. In this case, the intrusive thought isn’t just unwanted—it is unprocessed, still raw. Its fragmentation reflects the fact that it never made it into symbolic memory; it exists outside of chronological time and coherent narrative.

At the same time, we might also consider what relational function the fragmentation serves. It may not be only a collapse—it may also be a communication. That is, the fragmentation itself may carry an implicit message: “This is beyond language. I cannot hold it—can you?” In that sense, the adolescent may be using fragmentation as a way to test the container—to see whether the analyst can survive the flood without retreating into interpretation, reassurance, or silence. It is, paradoxically, a gesture of hope: that someone might receive the chaos and not be destroyed by it.

So, when we hear this kind of speech in early sessions, we begin to wonder: is this a mind under siege from within? Is this trauma that has never been symbolized? Is this a moment of collapse, or a plea for containment? All of these remain live hypotheses. And our role, in that moment, is not to sort or decode too quickly, but to listen with a mind that can bear not knowing. The therapeutic task is to become the function the mind itself lacks: a thinking container. We survive the flood. We hold. We don’t rush toward meaning. We name what we see—“That came out fast,” “Something feels too big to hold”—and we offer the adolescent a space where terror might one day be translated into thought.

That is the clinical attitude required here—not cleverness, not interpretation, but the quiet endurance of someone who can listen to the storm without running from it.

2. Flat – Disavowal / Psychic Withdrawal

Dr Harris Let’s move now to our second mode of presentation: disavowal—what we might think of as psychic withdrawal. Here, the adolescent doesn’t fall apart, as in fragmentation. There’s no explosion. No rupture. On the contrary, things seem... intact. But emotionally, something’s missing.

We’re no longer in the territory of raw affect—we’re in the realm of affective deadness. The adolescent may describe disturbing or violent images, but they do so with an emotional flatness that feels incongruous with the content. It’s not repression—because the thought is conscious. But it’s kept at arm’s length. It’s acknowledged without being felt.

Here are some classic examples:

“I keep imagining my mum gets hit by a car. I don’t know. It just happens. Whatever.”

“I think about stabbing someone, but it’s just a thought. Everyone gets those, right? I don’t really care.”

“Sometimes I imagine jumping off something high. But that’s not like... suicidal or anything. It’s just a thing my brain does.”

“I get these sex thoughts. Doesn’t mean anything. They’re just random. My mind’s weird.”

The tone is casual, uninvested—almost bored. But listen closely: this isn’t neutrality. This is evacuation of affect. The image is horrifying, but it lands in the room with no temperature. That’s the clue. The psychic function here is not communication—it’s defensive distancing. The adolescent knows the thought is disturbing, but they’ve sealed off the feeling. The internal system is saying: “This is dangerous material, and I will not engage with it.”

This often follows trauma—or situations in which emotional contact was punished, ignored, or simply too painful to bear. So the mind develops a kind of inbuilt anaesthetic. Not a lie. Not denial. Something subtler: disavowal—“Yes, that thought exists, but I will not let it touch me.”

Dr. Harris:

No affect. No panic. No horror. Just a report.

Psychic function? Disavowal.

The child may know the thought is frightening, but they’ve sealed off the emotion. Often this is a trauma residue—the mind protecting itself by flattening contact.

Dr Lewton:

Listening to that utterance—“I keep imagining my mum gets hit by a car. I don’t know. It just happens. Whatever.”—you can begin to sense the psychic maneuver at work: a deliberate cutting of affect from image. The thought is horrifying, but it’s delivered without emotional charge, without urgency. And that flattening is meaningful.

One early hypothesis we might hold is that feeling itself has become dangerous. That could be a developmental adaptation—perhaps the adolescent has grown up in an environment where emotion was punished, dismissed, or pathologized. Or it could reflect a more internal re-organization, where affect is now experienced as overwhelming, intrusive, even humiliating—and so the mind does what it must: it distances, it disavows, it flattens.

We might also wonder about the relational function of this flatness. In a session, it’s easy to feel pushed out by it. There’s a message in the tone, however unconscious: “Don’t react. Don’t feel more than I’m feeling. Don’t come too close.” In that way, the disavowal becomes a kind of perimeter defense—a relationally organized withdrawal that says, “Yes, something awful is happening in my mind. But no, I don’t want you involved in it.”

So while the content might suggest trauma, violence, or anxiety, the form of the delivery tells us the affect has been quarantined. Our task is to notice that—the mismatch between content and tone—and to hold in mind the possibility that this young person is not indifferent to the thought, but is surviving it by suppressing all contact with its emotional meaning.

Dr. Harris (responding to Dr. Lewton):

Yes, quite right—what you’re pointing to is the defensive logic beneath the flatness, and I think that’s essential. Let me take your formulations a little further.

You said: perhaps emotions are seen as dangerous or weak. Yes—and I would add, not just dangerous to express, but dangerous to experience. In some internal worlds, the emergence of affect itself is experienced as a threat to cohesion. For these adolescents, emotion is not simply disruptive—it is annihilating. So the mind organizes itself not around expression, but around suppression—around pre-emptive psychic withdrawal.

Now, what’s interesting is that this withdrawal doesn’t always take the form of silence or avoidance. Here, it takes the form of technical compliance: the adolescent speaks the words, offers the content, but strips it of emotional charge. The horror is mentioned but not felt. This is the structure of disavowal—the mind acknowledging something too painful to be consciously registered by splitting content from affect.

And as you pointed out, this may also have a relational dimension. We might wonder: is the adolescent telling us something about what we’re allowed to feel in the room? Perhaps the “whatever” is not indifference, but a kind of silent boundary—a way of saying: Don’t you dare empathize too much. Don’t try to make this real. In this way, the flatness becomes not just a self-protection, but a regulation of the analytic relationship.

In such moments, our intervention has to be very finely calibrated. We don’t inject emotion where none can safely exist, but we do gently acknowledge the gap:

“It sounds like this thought visits you often—but I’m wondering what it costs you to keep it sounding like it doesn’t matter.”

We’re inviting awareness without demanding contact.Because when emotion has been historically overwhelming or psychically toxic, flattening is not resistance—it’s refuge.

Participant (P5) Is there a way to tell if the flatness is defensive disavowal or just a developmental aspect—like, some adolescents are just matter-of-fact or emotionally avoidant by temperament?

Dr. Harris:

That’s a key question, and it gets to the heart of clinical listening. Not all flatness is pathological—some young people are simply understated, reserved, or not emotionally expressive by nature.

But here’s the distinction: temperamental flatness tends to feel consistent and integrated, like part of the adolescent’s personality. It’s not emotionally reactive—just a cool surface.

By contrast, defensive flatness tends to show up in specific emotional contexts—especially when the material is painful, frightening, or potentially overwhelming. It’s more like the mind shutting a door in real time.

Dr. Lewton:

Exactly. You often feel it in the room. There’s a kind of disconnect—like they’re talking about something that should carry weight, but it lands with a shrug. You might feel puzzled or even slightly chilled. That internal incongruence—the mismatch between what’s said and how it’s said—can be your first clue that we’re dealing with disavowal, not temperament.

Participant(P2):

Could disavowal be socially learned? Like, if the adolescent grew up in a family where sarcasm or deadpan delivery was the norm—could that be shaping this presentation, rather than trauma per se?

Dr. Lewton:

Absolutely. Disavowal can be inherited, in a sense—not just genetically, but relationally. If a child grows up in a household where emotional expression is ridiculed, ignored, or punished, they learn quickly to adapt. They may even absorb a kind of emotional posture from the adults around them: a stiff upper lip, a sarcastic tone, a tendency to downplay distress.

Dr. Harris:

Right, and in these cases, the adolescent may not even know they’re doing it. It’s just “how people talk” in their world. But even if it’s learned rather than trauma-driven, the psychic function is the same—it protects the person from emotional contact that feels risky or destabilizing. And that’s what matters clinically. Whether it came from trauma or environment, it tells us: something about feeling was not safe.

Participant (P4):

What if the adolescent shows no emotional response when speaking about the intrusive thought, but later in the session becomes tearful or anxious about something unrelated—does that suggest the disavowed affect is still accessible elsewhere?

Dr. Harris:

Yes—and that’s an important observation. Emotions don’t vanish. When they can’t attach to the thought that provoked them, they often find other routes—what we might call displacement. So you might see flatness around the intrusive thought, but emotional intensity later when talking about something seemingly benign: schoolwork, a friend, even the weather.

Dr. Lewton:

That’s a clue the system isn’t completely shut down—just that the emotion has been rerouted. In those moments, it can be helpful to gently link the two:

“I’m wondering if the sadness that came just now might be connected to what you said earlier, about imagining your mum getting hurt.”

We’re not pushing—but we’re offering a possible bridge between islands of feeling.

Participant (P4):

Would it ever be appropriate to gently confront the disavowal—like saying, “That’s an awful image, and I’m struck by how little feeling you show when you say it”? Or is that too exposing, too soon?

Dr. Lewton:

It depends on timing and tone. That kind of intervention can be powerful—but only if the relationship is strong enough to hold it. Early on, saying something too direct can feel like an emotional ambush.

Dr. Harris:

That’s why we suggest marking the absence rather than confronting it. Instead of “You’re not feeling anything,” we might say:

“That’s a disturbing image, and you tell it so simply—I’m wondering what it’s like to say it out loud.”

That invites reflection without forcing it. It keeps us in a curious, holding posture, rather than a confrontational one. And it leaves room for the adolescent to feel the affect when they’re ready, rather than shutting down further.

Participant (P6):

How do we work with this kind of flatness over time—do we wait for affect to return spontaneously, or is there a way we help the adolescent recover emotional contact with the thought?

Dr. Harris:

We don’t wait passively, but we don’t push either. Our job is to build a context where feeling becomes safe again—where emotion can emerge without threat of collapse or exposure.

Sometimes that means narrating what we observe in a grounded, gentle way:

“You’ve talked about that image a few times now—it seems like it’s part of your world, but hasn’t touched you much yet. I wonder if that’s something you’ve had to get used to, in order to manage it.”

That’s not asking them to feel—it’s helping them think about why feeling might not be present.

Dr. Lewton:

Over time, if the therapeutic relationship holds, you often see little shifts—tone changes, metaphors emerge, a flicker of discomfort. Those are openings. And when they come, we meet them with care. We don’t label them too quickly. We let the feeling arrive, find its form, and stay with it—not fix it.

I would say that the idea is to “Wonder about the absence.”

“You’re telling me something a lot of people would find scary. But I notice it sounds very flat. I wonder if it feels safer that way?”

We’re not asking them to feel. We’re wondering about why they don’t. But not saying that directly as that would push them further away from the affect.

Participant (P4):

Yes, I really agree with that—it’s something I find myself saying a lot in supervision. It’s really hard to teach this core idea to trainees and early-career counsellors—that direct “why” questions often don’t work.

They can land as interrogative—even when they’re well-meant. Especially with adolescents, who are already feeling watched, judged, or misunderstood. “Why don’t you feel scared?” or “Why do you think that doesn’t bother you?”—those kinds of questions can just make them shut down more.

Dr. Harris (responding):

Yes—absolutely. That’s a vital observation, and it goes right to the heart of how we think about containment in the therapeutic encounter.

“Why” questions are, in theory, about understanding. But in practice—especially in moments of psychic withdrawal—they often land as demands for explanation. They assume that the adolescent can access the answer and, more importantly, that they’re willing to share it with you.

But when a young person is operating in a disavowed state, they’re often not withholding affect—they’re cut off from it. So a “why” question, even if softly asked, can feel like being asked to perform insight they don’t yet have access to.

And as you say, adolescents in particular are exquisitely sensitive to being monitored. Their developmental task is separation, privacy, internal sovereignty. So if a question feels like surveillance—even subtle surveillance—it risks triggering further withdrawal.

So instead, we shift from interrogation to observation-without-intrusion. We say things like:

“You’re telling me something that sounds like it might be scary for some people… but I notice you say it so calmly. I wonder what it’s like to talk about it that way.”

Or even:

“It’s interesting—there’s something about how you’re describing it that feels very calm, maybe even distant. I wonder if that’s how it feels on the inside too?”

These aren’t why questions—they’re wondering statements. They don’t presume access or demand explanation. They simply mark what’s missing—and then make space for it, if it wants to arrive.

And that’s what we mean when we say we’re not asking them to feel—we’re wondering about what’s not being felt, but doing so with enough distance that we don’t provoke more disavowal.

This is not about technique. It’s about tone, timing, and trust. And as you said—it’s hard to teach. But it’s what makes the difference between being a questioner and being a container.

3. Over-Controlled – Mastery & Containment

Dr. Harris:

Let’s move now to the third mode of thought presentation: over-controlled, or what we might describe structurally as mastery in the service of containment.

Now this is, in many ways, the opposite of what we saw in fragmentation. There’s no collapse here. No flood of affect. No syntactic disintegration. In fact, it can feel almost reassuring—this adolescent speaks clearly, sequentially, often with a kind of mechanical self-awareness. But that control is not a sign of integration. It’s a sign of pressure. Of fear held in check through sheer force of cognition.

Here, the psychic function of the intrusive thought is being dominated—held down, tightly managed. The adolescent is performing a kind of internal surveillance. Not symbolising, not exploring—but monitoring, tracking, quantifying. Speech is clipped, even rehearsed. And yet, when you listen closely, you can hear the strain under the surface—the white-knuckle grip of a mind trying not to be overwhelmed.

Let’s look at an example:

“I’ve had the same thought 37 times in the last 24 hours. I’ve written it down. I’m tracking the triggers. It’s the image of me choking my friend. I would never do that, obviously.”

You can hear the tightness. The compulsive accounting. The disavowal neatly sewn into the tail end: “I would never do that, obviously.” The voice of fear is carefully silenced—but still there, just beneath the surface.

Let me give you a few more examples of this mode, so you can tune your ear to it:

“I’ve created a log. It tracks what time I had the thought, what I ate beforehand, and what I was doing. I’m trying to see the pattern.”

“It happens mostly in the afternoon. I think that’s because I’m tired and more vulnerable to distorted cognition. I’ve read that’s a trigger time for intrusive thoughts.”

“I’ve listed all the situations where the thought appears, rated them out of 10, and written down what I told myself afterwards. That helps keep it in perspective.”

In each case, what you’re hearing is a cognitive fortress—a mind that’s trying to beat the thought with more thought. And it’s often impressive. These adolescents can sound advanced, insightful, even clinically fluent. But underneath the fluency is something deeply fragile.

This kind of adolescent often positions the clinician as a technician: “Here’s my data, tell me how to fix this.” There’s little emotional curiosity—only a hope that if enough facts are shared, the problem will be solved without needing to feel anything.

What we must remember is that this over-control is not just a coping strategy. It’s a defensive posture. The emotional logic beneath it is often: “If I let go even a little, I’ll fall apart.” So we tread lightly. We don’t try to dismantle the system. We start by acknowledging the effort it takes to keep it running.

Dr Lewton:

Yes, I think when we hear this kind of clinical presentation—precise, measured, hyper-organized—we’re not just seeing someone managing a thought. We’re seeing someone defending against being overwhelmed by it. Often, these adolescents rely heavily on rationalisationand intellectualisation—not just as coping mechanisms, but as a kind of emotional firewall. Their thinking becomes a fortress. The numbers, the tracking, the rehearsed phrasing—it’s all part of a system designed to keep affect at bay.

Now, there’s a part of this that’s adaptive. It gives them a sense of agency—“If I can quantify it, I can control it.” But over time, it narrows their emotional repertoire. The internal world becomes over-regulated, even sterile. And what’s striking is how they position the clinician: not as someone to help them feel, but as a kind of consultant. They bring the thought like a case file—“Here’s the data. Please fix it.”

You can sense, sometimes, how much importance they place on the precision. There’s an unconscious hope that if they can explain the thought clearly enough, thoroughly enough, it might be solved without ever having to be felt.

And interestingly, this pattern isn’t limited to the adolescent. You often see it mirrored in clinical systems where the medical model dominates. You’ll get detailed referrals—page after page on the frequency and nature of compulsions—as though accumulating data equals understanding. But often, these details are psychic noise. They don’t bring us closer to the emotional meaning of the thought—they reinforce the fantasy that if we just “know enough,” the thought can be mastered. But as Dr. Harris has said, that’s the defense itself: containment in place of contact.

Dr. Harris (adding):

Yes—beautifully said. I’d just add one thing.

We must be careful not to mistake this control for stability. It often masks fragility. These adolescents aren’t calm—they’re clenched. The speech is crisp, but the psychic grip underneath is white-knuckle. And that’s where we need to listen—not to the elegance of the data, but to the urgency of the containment. What are they trying not to feel?

So our job, again, is not to challenge the control—but to make room around it.

“You’ve tracked this so carefully—I’m wondering what it’s like to be the one who has to hold it all together.”

We’re not interpreting. We’re loosening the structure—just enough—so that something else might come through.

Dr Lewton:

The appropriate response or responses would be Honour the containment, then offer relational holding.

“You’re doing a lot of work to manage this thought. I wonder what it’s like to have me help hold it with you—just for a moment.”

We do not strip the defence. We offer something stronger.

Participant(P1):

Isn’t this kind of over-controlled presentation preferable to fragmentation or emotional flooding? Shouldn’t we be encouraging this kind of organised response in therapy, especially early on?

Dr. Lewton:

It’s understandable to feel some relief when a young person presents in this way—there’s structure, there’s coherence, and they can talk. And yes, it’s more tolerable than total disintegration. But it’s important we don’t confuse control with health.

This isn’t a mind at peace. It’s a mind on high alert, trying to out-think a fear it doesn’t feel safe enough to feel. The presentation is organised, but it’s often driven by an unspoken terror of what might happen if the structure slips. That’s not the same as emotional resilience—it’s often closer to psychic survival.

Dr. Harris:

Exactly. Control, here, is not integration—it’s substitution. The adolescent isn’t digesting the intrusive thought—they’re gripping it, hoping that if they measure it precisely enough, it won’t explode. Our task isn’t to take that control away, but to help them discover that they don’t have to rely on it so absolutely.

Participant (P2): How do we avoid reinforcing the control? If they come to us with spreadsheets, diaries, data—won’t engaging with that just strengthen the defence?

Dr. Harris:

That’s a crucial point. We must be very careful about how we listen.

If we dive into the data—“When did it start? What were you doing before?”—without pausing to think why the data is being offered so obsessively, we risk colluding with the defence. We join the system that is already over-invested in containment through cognition.

So instead, we acknowledge the effort, and gently pivot:

“You’ve clearly been working hard to track this. I wonder what it’s like having to monitor your thoughts so closely.”

That opens a door to meaning without dismissing the structure they’ve relied on.

Dr. Lewton:

And importantly, we don’t pathologise the data. We treat it as a clue. The form of the communication—its obsessiveness, its precision—is telling us something. We don’t ignore it. We reframe it.

Participant (P3):

If they’re so focused on problem-solving, how do we begin to shift toward emotional understanding without breaking the alliance?

Dr. Lewton:

Start where they are. If they come in asking, “What should I do when I get the thought?”, you don’t say, “Let’s explore your inner world.” That will lose them. Instead, you meet the problem-solving energy, but use it to introduce emotional reflection.

For example:

“That makes sense—you want to know what to do. But I’m also curious—what do you imagine would happen if you didn’t control the thought so precisely?”

You’re still in the realm of the thought, but you’re expanding the frame—introducing the idea that the feeling beneath the control might be the real thing to understand.

Dr. Harris:

Well put. And over time, we build a capacity for feeling. Not by dismantling the control directly—but by offering a relationship in which the adolescent is not required to be in control at all times. That’s what opens the space for emotional contact.

Participant (P4): Could the precision and control also be a way of trying to “perform well” in therapy—like they think you want data, so they’re giving you what they think therapy requires?

Dr. Harris:

Yes—and that’s very astute. Some adolescents are trying to be the perfect patient. They bring you evidence, reports, “homework,” because they believe that’s how therapy works: If I give you good information, you’ll make me better. It’s a very concrete relationship to help.

But underneath that performance is often anxiety about not being understood, or not being helped unless they “get it right.” So we can acknowledge the effort while shifting the frame:

“You’ve given me a really clear picture of what happens. I wonder what it’s like for you to have to be that clear.”

We’re saying: I see what you’re doing, and I’m curious about why you feel you have to do it.

Dr. Lewton:

And we’re modelling something else: that therapy isn’t about performing well—it’s about being real, even if what’s real is messy or uncertain or unfinished.

Participant (P5):

If the adolescent says they feel “in control” and doesn’t want to explore further, do we just respect that? Or is there a way to invite more without pushing?

Dr. Lewton:

We always respect the defence. But we stay curious about it.

You might say something like:

“It makes sense that you’ve worked hard to manage this. And I hear that you feel in control. I guess I’m wondering—what happens if we talk about the part that’s hard to control?”

We’re not pulling the defence away—we’re asking permission to look around its edges.

Dr. Harris:

And we stay very close to language. If they say, “I’m in control,” we might wonder what that means to them. What would not being in control look like? What’s the fear underneath it?

You’ll often find that “being in control” is a way of saying, “I can’t afford not to be.”

Participant (P7):

I really loved what was said earlier—that image of adolescents holding the thought in a clenched way. That’s exactly what I’ve seen, but I hadn’t found the words for it until now.

I’ve worked with many adolescents who provide these over-inclusive, meticulous descriptions of their intrusive thoughts. At first, I find myself getting excited. They seem so open, so eager to talk—especially compared to the ones who are avoidant or shut down. And from more of a CBT perspective, it can feel like, “Well, this is great—they’re doing half the work for me.” You just need to help them reframe it, right?

But then you hit a wall. They’re not actually curious about the thought—they’re collecting evidence. You suggest something, they come back with more data. There’s no movement. It’s just... tight.

So when you said the word “clenched,” that really landed. It’s not that they’re terrified of the thought—they’ve got it in their grip. They’re managing it, yes—but it’s exhausting. For them and for us.

Dr. Harris (responding):

Yes, beautifully observed. That’s the trap of the well-spoken, over-articulate adolescent—they can look like they’re engaging when what they’re actually doing is managing the encounter. And because they’re talking so much, and so clearly, it can feel like the work is happening. But as you’ve noticed—there’s no symbolic play, no curiosity, no psychic movement.

And that word you used—exhausting—is spot on. These adolescents often leave the session feeling depleted. Not because they’ve felt something unbearable, but because they’ve worked so hard to keep feeling out. The grip itself is what drains them.

What we’re hearing is a mind that’s built a system around the thought, not to understand it, but to dominate it. It’s mastery in the service of avoidance. And the moment we offer something that invites feeling, uncertainty, or relational contact, they shut the gate and offer us more content—more facts, more triggers, more lists. It’s a form of compulsive thinking, but with a relational function: “Don’t get near me emotionally—here’s more information instead.”

And what’s crucial is not to treat this as resistance or rudeness. This is a defensive structure that’s working overtime to keep something out. Not just anxiety—but often shame, helplessness, or unmetabolised rage.

So yes, they look in control. But the control is often a defence against collapse.

Participant (P6):

But this is the tension, right?

They don’t want to talk about their feelings. They want solutions. We’re the expert. They’ve come to us because they believe we have tools, strategies—fixes.

And when parents also collude with this “anal problem-solving” approach—as in, “We just want a plan. What should they be doing each day?”—the whole system is organised around control. Around doing, not feeling. It can feel impossible to create space for emotional work when the entire ecosystem—the adolescent, the parents, sometimes even the school—is invested in managing the problem like a spreadsheet.

Dr. Lewton (responding):

Yes, I know that feeling well. That moment where you look around and realise everyone in the room—the adolescent, the parents, even part of yourself—is caught in the fantasy that if we just get the right plan, everything will settle.

And that’s why we have to offer something different in the room. We’re not there to compete with their problem-solving mode. We’re there to model a different kind of attention. One that tolerates not knowing. One that makes space for ambiguity. One that says: “You don’t have to be efficient here. You don’t have to perform wellness. You can just be.”

We’re not dismantling their control—we’re offering a different rhythm. And often that begins with a very quiet shift. A moment where we say:

“You’ve really thought this through. You’ve tracked everything, you’ve built a system. And I wonder what it’s like to carry that system every day.”

That’s not a challenge—it’s an invitation. And sometimes, that’s the moment where something softer emerges.

4. Rehearsed Shame – Internalised Superego Attack

Dr. Harris (speaking to the room):

Let us move now to the final mode of thought presentation—one that many of you will recognise immediately, and one that can be especially difficult to sit with. We might call it Rehearsed Shame, or more structurally, an expression of an internalised superego attack.

Here, the content of the intrusive thought matters far less than the tone in which it’s delivered. The adolescent is not sharing the thought—they are condemning themselves through it. The thought becomes the instrument through which the self is attacked.

Let me give you the example we opened with:

“I know it’s disgusting. I’m disgusting. No one else thinks like this. I’m sick. I know I am.”

Notice the structure. The cadence. There’s a rhythm to it—a ritualistic tone. It’s not an emergent thought. It’s a recitation. A script that has likely been rehearsed, repeated silently, for days or weeks or months. The thought is no longer the source of distress—the self is. The psychic function here is self-attack as pre-emptive protection.

This is not guilt. This is shame, weaponised against the self. The adolescent is saying: “I already know I’m disgusting. I’ve already punished myself. So you don’t have to leave me. You don’t have to hate me. I’ve beaten you to it.” That’s the emotional logic.

Let me give you a few more examples to help you tune your ear to this particular register of speech:

“I know this probably makes me a paedophile. I don’t want it to, but I think it does. There’s something wrong with me. I’m sorry.”

“I wouldn’t blame you if you didn’t want to see me again after what I just said.”

“I’ve looked online. People like me don’t get better. I’ve probably already gone too far.”

“I should just stop talking—I always make it worse. I shouldn’t even be in therapy.”

“I’ve had bad thoughts about my little brother. I’m a monster. I don’t deserve help.”

What’s important in all of these is the posture. The adolescent is not seeking comfort. They are preparing for exile. The shame is not spontaneous—it’s managed, performed, even offered up as a kind of ritual sacrifice to avoid something even worse: being seen, being understood, and still being rejected.

And this is what makes the work so delicate. Because if we rush to reassure—“You’re not disgusting, you’re just struggling”—we risk colluding with the internal split. We comfort the conscious self while leaving the unconscious wound untouched.

Instead, we stay close. We name the structure. We might say:

“It sounds like this thought has convinced you that you’re unforgivable—and you’re trying to tell me that before I can even think it.”

Or:

“It feels like you’ve already put yourself on trial in your head—and handed down the sentence.”

These are not interpretations. These are invitations to self-recognition—a way to gently hold up a mirror to the superego’s voice without escalating the attack.

This adolescent isn’t asking you to fix them. They’re asking—can you survive hearing this, and still stay in the room?

Dr Lewton:

Yes—this mode is incredibly common, and incredibly painful to witness. As Dr. Harris says, it’s a performance of shame—and one that’s often rehearsed, internalised, and automatic. You can almost hear the punctuation in their tone: “I know. I’m disgusting. I know I am.” It’s not being discovered in the moment—it’s being declared, as if the lines have been memorised.

What we’re really hearing is something like: “Let me attack myself before you do. Let me be the one to name how awful I am, so you don’t get the chance to walk away in disgust.” It’s a pre-emptive strike against perceived rejection. The adolescent is often terrified that their thoughts—especially intrusive ones that involve violence, sexuality, or taboo impulses—make them fundamentally unlovable. So they turn the knife inward.

You’ll hear different versions of this:

“I’m a terrible person.”

“I know I deserve whatever happens to me.”

“I wouldn’t blame you if you stopped seeing me.”

All of these aren’t just expressions of low self-worth—they are attempts to control the emotional field. To say, “I already know how bad I am, so don’t punish me—just stay.”

Now, what does Dr. Harris mean when he says the thought is secondary and the performance of shame is primary?

I think he’s saying: in this moment, the content of the intrusive thought—whatever it is—is not the real communication. It could be about harming someone, or having a blasphemous image, or a sexual impulse—but that’s not what the adolescent wants us to focus on. What they are really expressing is: “Look how ashamed I am. Please see that I hate myself for this. Please don’t leave.”

The shame is doing a relational job. It’s saying: “Don’t abandon me for this thought. I’ve already punished myself.”

So our job, in that moment, is not to interrogate the thought, or even to reassure them that they’re not bad. It’s to respond to the loneliness beneath the shame—the desperation to be met not with disgust, but with humanity.

Sometimes that might sound like:

“You’ve had this thought, and it sounds like it makes you feel sick. Like you’re already on trial in your own mind before anyone else has had the chance to judge.”

That opens the door to thinking: Why does this mind need to attack itself in order to feel safe?What would happen if we didn’t join in the condemnation?

Dr. Harris (adding):

Yes—precisely.

The shame here is not a response to the thought. It’s a strategy. The adolescent has learned—often unconsciously—that if they lead with self-attack, they can prevent others from doing it first. So the shame is not just affect—it’s a manoeuvre. A way to hold on to relationship in the face of unbearable anxiety about rejection or exposure.

And that’s why we say the thought is secondary. It’s the vehicle. The real message is: “I know I’m unworthy. Will you stay anyway?”

And that is the real clinical question in the room: Can we hear the shame without colluding with it? Can we offer containment without rescuing?

That’s the therapeutic task.

Participant (P8):

I just want to say—I find this particular mode the hardest to work with.

There are adolescents who come in and say something like, “I know I should talk about the thoughts—but honestly, every time I do, I just feel worse. I don’t think it helps.” And there’s a way they say it where I don’t think they’re just avoiding. It’s like they’ve already decided it won’t work. The shame is so baked in, they expect it to be useless—or to make them feel even more disgusting.

What you just said now makes me think maybe that’s the superego talking—but in the moment, I feel completely stuck. What would either of you say in that moment? I’ve heard it so many times and I never know what to do.

Dr. Harris (responding slowly, with quiet precision):

Yes—that’s a profoundly difficult moment, and I think it’s good to name how stressful it can feel. Because what you’re encountering there isn’t just reluctance—it’s a collapsed hope structure. They’ve already tried talking to themselves about the thought. Likely rehearsed it over and over. Judged it. Condemned it. And nothing has relieved it. So now, when they say it to you, they’re preparing to fail again.

They’re not saying, “I don’t want to talk.” They’re saying, “I’ve already concluded that talking won’t rescue me.” And the worst part is—they’re half-expecting you to agree.

So in that moment, I would not argue. I wouldn’t try to convince them. I might say something like:

“That makes sense. If every time you’ve spoken about it, you’ve ended up feeling worse—it’s no wonder you’re hesitant now. I’m not going to force it. I just wonder if there’s a way we can hold the thought differently—not to fix it, but so you’re not carrying it alone.”

Or, if I sense there’s more silence:

“I hear you saying that talking doesn’t help. And maybe part of you is bracing—waiting to feel worse again. I wonder if we could think about why that happens together, without needing to go into the detail of the thought just yet.”

In both cases, we’re not denying their experience—we’re respecting it. But we’re also gently pushing open a door to thinking together, rather than confessing alone.

Dr. Lewton (picking up, more emotionally present):

Yes—I love how you’ve put that, Dr. Harris. And I’d just add this:

When a young person says, “Talking makes it worse,” I often hear a kind of exhaustion behind it. It’s not resistance—it’s despair. And I try to let them feel that I’ve noticed that, without jumping in with reassurance.

So I might say something like:

“Yeah. I can hear how tired you are of this. And maybe when you’ve talked about it before, it felt like no one really understood what it was like—they just wanted to make it go away. So even talking felt like more pressure.”

Or sometimes, even simpler:

“I don’t think you’re saying you don’t want to talk. I think you’re saying you don’t want to feel worse—and that makes complete sense.”

And then I leave it there. I don’t try to dig. Because what I’m doing is building the frame of trust. I’m saying, “You’re safe. I’m not going to pull you into something painful just to make myself feel helpful.”

And more often than not, once they feel that—they do start talking. Maybe not that day. But soon.

Participant (P1): Is there a risk that if we don’t actively challenge the self-hatred, the adolescent will just stay stuck in it? Shouldn’t we be helping them see that the thought doesn’t make them disgusting?

Dr. Harris:

Yes—this is a delicate balance. The instinct to reassure is very human, and in everyday life, it might even be helpful. But in the clinical space, reassurance can sometimes short-circuit the deeper process. If we rush to say, “You’re not disgusting,” we may unintentionally invalidate the depth of the internal attack. The adolescent may hear, “You don’t get it.”

So instead, we meet them where they are:

“It sounds like this thought has convinced you you’re unworthy of being cared for.”

That keeps us with the experience, rather than arguing against it.

Dr. Lewton:

Exactly. And when they feel truly heard in the shame—without us flinching from it—that’s often what creates movement. The shame becomes less necessary when it’s no longer performing a relational job. So it’s not that we don’t help them move past it—we just don’t fight it head-on.

Participant (P2): Could this kind of self-attack come from cultural or religious messaging, rather than just individual pathology? How do we make space for that?

Dr. Lewton:

Absolutely. We can’t understand shame without context. Many adolescents grow up in environments—familial, cultural, religious—where certain thoughts or impulses are framed as not just wrong, but soul-endangering. That kind of moral framework doesn’t just produce guilt—it can produce identity-level shame.

So we have to listen carefully for whose voice the adolescent is internalising. Sometimes the superego monologue we’re hearing isn’t theirs—it’s their parent’s, their priest’s, their community’s. And rather than pathologising it, we can gently name the conflict:

“It sounds like this thought puts you in conflict with something you’ve been taught is sacred.”

That honours the moral seriousness of their struggle while still creating space to think.

Participant (P3): What if the shame is so strong that they won’t tell you the actual intrusive thought? How do we work with that when the content is hidden?

Dr. Harris:

We don’t need the content to work with the communication.

In fact, the withholding itself becomes the material. If a young person says, “I can’t even tell you, it’s that awful,” we might say:

“It sounds like the thought is one thing—and the shame it carries is another. Maybe the shame is what really hurts.”

By focusing on their emotional posture—the hiding, the disgust, the fear—we can begin working with the relational structure, even if the exact image or idea isn’t spoken aloud.

Over time, if the space holds, the thought may eventually come forward. But it’s not the disclosure that transforms—it’s the experience of not being abandoned when the self feels most contaminated.

Participant (P4): If the shame is a kind of script, how do we know when we’re hearing the authentic adolescent and not just the superego talking?

Dr. Harris:

A beautiful question—and an important one. Shame has a certain texture when it’s rehearsed. You’ll hear the tight phrasing, the recycled language, the certainty—“I know I’m disgusting.” It feels fixed, not discovered.

But sometimes, if you stay with it gently, something new will slip out—often quietly, almost by accident:

“I don’t know why I keep thinking it.” Or, “I hate that it’s in my head.”

That’s the real voice—vulnerable, unsure, searching. It’s not the superego shouting; it’s the self peeking through.

Our role is to help make that space safe enough that the script loosens, and the person emerges.

Dr. Lewton (closing the seminar):

Thank you, everyone.

What I hope we’ve offered today is not just a lens for understanding intrusive thoughts, but a way of listening—a listening that attends not only to what is said, but how it is said. Because beneath every symptom is a structure, and behind every structure is a psychic manoeuvre—an attempt to manage unbearable experience, or to stay in relationship when the mind feels at risk.

What we’ve seen across the examples—from fragmentation, to disavowal, to control, to shame—is that intrusive thoughts aren’t random invasions. They’re shaped by internal worlds. And the way they are spoken—hurriedly, flatly, precisely, or with disgust—tells us how the adolescent’s mind is trying to survive them.

And what they need from us, before they need insight or solutions, is a listener who won’t flinch. Someone who can bear the storm without rushing to fix it. Someone who can survive the flood.

Thank you all for your presence, your questions, and your thoughtful attention.

Dr. Harris (concluding):

Intrusive thoughts wear many disguises. But in every case, we must ask: What is the psychic structure from which this utterance emerges?

Don’t be seduced by content.

Don’t be paralysed by affect.

Listen for the shape. And when you find it—hold it.