Real-Time Treatment: Integrating Neuroscience and Psychoanalysis in the Intensive Treatment of Emerging Adults
April’s debut night in the Yellowbrick Residence was memorable for all involved; she had sexual encounters with two of the male residents, a third young man she also just met that day in our Intensive Outpatient Program, and his three roommates! Why, you might ask, did we not discharge her immediately, sending her to a more restrictive therapeutic environment where such behavior would be controlled and prevented? After all, April had gotten herself kicked out of every treatment program she ever entered. She was 22 years old, raised on the North Shore, a college drop out, with a history of serious alcoholism and other substance abuse, compulsive sexual addiction, and wearing a scarlet “B” for an Axis II diagnosis, as she headed down the road to destroying her self regard, her relationships, and her capacity for hope.
So, why didn’t we kick her out after that first night… or the next time she exploded the limits? That is what I am here to talk to you about today… a model of treatment that seizes such a seminal moment as the perfect opportunity to re-network April’s brain… actually rebuild and reconnect the neural circuits for self-organization and function, secure attachment, and effective life skills. It is a Developmental Neuro-Psychoanalytic model for intensive treatment of severe psychopathology in Emerging Adults. I will present the theoretical and scientific basis for each element of this model, as we developed it at Yellowbrick, by following April through subsequent, and much more meaningful, relational moments in her treatment within Yellowbrick.
As an emerging adult, April is in a developmental period of great risk and also of great potential. Developmental psychologist and researcher Jeffrey Arnett was the first to identify the period between ages 16 and 29 as a distinct developmental phase and to term it Emerging Adulthood, the age of possibilities. Arnett’s decade of research in normal development identified the 5 primary features of this period as: 1) the age of identity exploration, especially in love and work, 2) the age of instability in all areas of life, 3) the age of feeling in-between adolescence and adulthood, 4) the most self-focused age, and 5) the age of possibilities and opportunities to create the future. As a normal part of this developmental period, the emerging adult is experimenting with everything…from drugs and alcohol, to sexual partners, to lifestyle patterns, to career opportunities, to social and political identities…literally every aspect of their lives is in transition, becoming... Think for a moment about your own life… what were you doing during college? Was anybody else with me at Woodstock?! If you say you remember Woodstock, I know you weren’t really there!
Emerging adulthood is also the age when risk factors are highest… drug and alcohol misuse, unwanted pregnancies, suicide as the second leading cause of death surpasses only driving accidents. 75% of all major psychiatric illness begins during this period. 18% (6.4 million) of 16-25 year olds are diagnosed with major psychiatric illness and 7% are seriously functionally impaired. Of those with emotional and behavioral difficulties, the risk of failure to complete school is 14 times greater; the rate of being out of school and unemployed is 4 times greater; the risk of illegal activity is 3 times greater; and the risk of pregnancy is 6 times greater than their peers.
Emerging adulthood is a window in human development combining great risk and even greater possibility. Going beyond our own clinical wisdom and empirical experience, new neuro-imaging technologies inform us that there is another generation of synaptic sprouting and pruning in the areas of the brain linked with self-regulatory functions that occurs during this time of life ( ). While psychopathology from early life experiences may be in full force, unlike in earlier adolescence, brain maturation in emerging adulthood is bringing new resources to the challenges of self-organization and psychic integration. This makes emerging adulthood an ideal time for psychotherapeutic intervention; a time when a young person like April can have the trajectory of her entire life redirected. Gunderson ( ) and recently McGlashan, et.al. ( ) have also demonstrated that aggressive intervention for severe personality disorder leads to better outcome and course in the treatment of co-morbid Axis I mood disorders.
Effective treatment of troubled emerging adult patients, such as April, requires that we do so in their world, standing alongside them, experiencing with them where and when they struggle, suffer, and are dysfunctional. The asylum (go away and get better) concept for programmatic treatment of emerging adults recapitulates an “as-if” power-based type of relatedness. It engages a developmental impasse regarding how to resolve dialectically opposing needs for both autonomy and connectedness by eliminating real-life, real-time choice. As a result, asylum treatment does not facilitate the depth of attachment, emotional immersion and the neuro-synaptic activation required for deep and enduring change in self-organization.
Jennifer Tanner conceptualized a developmental systems model of emergent adult development she calls “Recentering”. According to Tanner, developmental research shows that during emerging adulthood there is a shift away from family and neighborhood and toward greater individual identity, personal responsibility, personal power, self-regulation, and self-agency in the larger community and society as a whole. This is where we choose to work with April, to help her co-create her emerging world. We find Gedo and Goldberg’s model most helpful in guiding us in this process.