Jesse Viner, MD Laura Humphrey, PhD
Jesse Viner    Laura Humphrey

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Real-Time Treatment: Integrating Neuroscience and Psychoanalysis in the Intensive Treatment of Emerging Adults

Jesse Viner, MD, Founder and Executive Medical Director
Laura Humphrey, PhD

 

Gedo and Goldberg’s Developmental Arc of Self-Organization

In Models of the Mind  (1973), Gedo and Goldberg present a hierarchical model of intrapsychic development and self-organization. They identify 5 levels of developmental “aims”, “modes” of functioning, dangers, primary defenses, and corresponding empathic therapeutic interventions. Gedo and Goldberg break with established psychoanalytic theory in recognizing that the more archaic modes of functioning are not merely reflections of wishes which can be interpreted away; they represent actual needs within the current level of the patient’s self-organization and self-experience, and require a creative, empathic therapeutic response in order to repair and restore the patient’s self-organization. Gedo and Goldberg declare that this is not merely to prepare the patient for the real work of treatment, it IS the work of treatment even in psychoanalysis.

Let us consider such a crucible moment about 4 weeks into April’s stay at Yellowbrick. April told her apartment mate that she was bringing, to The Residence, a young man she met two days earlier at an AA meeting and that she planned to have sex with him. Her roommate was upset by this for a number of reasons and told one of the Residence Resource staff. Residents know that, while we safeguard their privacy, there is no confidentiality within the Yellowbrick community. All communications are considered to be within the public realm. It is especially the case that there are no secrets when it comes to symptomatic or unsafe behavior, or issues that affect others, including emotionally, within the community of residents. From a theoretical perspective, this community component of our treatment model addresses not only the obvious trauma-related issues related to boundaries and secrets, but is also instrumental to the process of mentalization. The construct of mentalization, was introduced by Fonagy ( ), as the capacity to conceive of the mental life of self-in-relation to others. We consider mentalization vital for healing and growth.

The Resource staff person communicated April’s plans that same day at 2:35 PM in the daily Clinical Conference where all professional staff meet together. April and her beau were planning to meet at 3 PM! At Yellowbrick, real-time sometimes means real fast! As would be the case with a caring parent, we were aware of the impulse to invoke our authority and step in with strong limits, preempting her plan by confronting April and preventing her from using “our” Residence for such purposes. We resisted this natural impulse, however tempting, as the Yellowbrick model specifically seeks to hold the dialectical tensions of these spontaneous emotion-filled moments and to avoid foreclosing their outcome. That would also pre-empt neurobiological re-networking. Instead, we chose an intervention born out of our understanding of the evolving principles of neuro-scientific studies on relational learning. Studies show that new learning takes place most robustly in the context of secure relationships and states of heightened, but not traumatic, arousal within which individuals have real choice and real responsibility (cite Siegel and Schore?). We utilized our understanding of April in this precise moment and, calling upon Gedo and Goldberg’s model, responded in the hope of  unifying April’s self-organization and enhancing the potentials to re-network her brain within that experience.

The discussion in Clinical Conference explored how April had begun to feel genuinely cared for and connected with her female individual therapist. She was beginning to allow herself to experience long warded off grief over the loss of her mother who died of cancer when she was a senior in high school. April’s relationship with her Mom had been very difficult and angry in the years prior to Mom’s death, leading to subsequent guilt and, in our view, self-degrading and punishing patterns of behavior. Her Mother, in April’s experience, viewed her as “a bad girl”. We understood that April’s yearning for her Mother was activated in the treatment and that she was pathologically in pursuit of the experience of connection to her Mother through this planned sexual encounter.

This connection would help to stabilize the grieving and strained self-organization, and provide a type of self-coherence, but with a pathological twist. By pursuing the need for closeness with her Mother through an anonymous sexualized form of self-unification, tragically, April would also reinforce the negative identity from that period, in her life with her Mother, when she consolidated the shameful bad-girl identity. A prohibitive and judgmental response by Yellowbrick would have reinforced the same negative self experience and identity. April needed not to be prevented from having sex, but to be provided an internalized motivation for self-restraint in the form of a mother’s respectful, hopeful love and holding containment.

So here’s what the Yellowbrick sex SWAT team decided to do. A female senior clinician, other than her individual therapist, was dispatched to The Residence to meet with April initially and then with her and the young man upon his arrival. The plan was to leave the ultimate decision to them but to speak with them about the meaning and feelings involved for each of them in their choices. They would specifically discuss April’s misuse of physical intimacy in seeking emotional intimacy and how that degrades her self and leads to later self-condemnation.

When April met with the clinician, she initially protested vehemently but eventually experienced and understood the caring nature of the intervention. While she retained the privilege as to who could and could not come to visit her in her apartment she had a responsibility to first respectfully (mentalization) fulfill certain obligations to herself and the community. She was requested to call the man and tell him that he would need to join her in a meeting with the staff person before visiting in the apartment. It was much like parents asking to meet a man before their daughter goes out for a date with him. April was very motivated to have the visit so she agreed and placed the call. 

What do you think happened? The young man said he had already decided it was wrong, against AA guidelines, and demeaning to them, their relationship and to their recovery. April burst into tears and sobbed; this was a resumption of the warded off mourning for her Mother. Now she could share, and receive comfort and understanding for, from the senior female staff member because of the process they had just been through together. While not immutable, we believe there is evidence that this experience has been transforming. April has not had an impulsive sexual encounter with anyone in the 10 weeks since, despite impulses to do so, which we believe represents a new development in the structure of April’s mind-brain.  

This Real-Time intervention took place within a larger treatment context at Yellowbrick which is founded on Gedo and Goldberg’s model of psychotherapy for the three most archaic modes of psychic organization, namely, therapy via pacification, unification, and optimal disillusionment (Gedo & Goldberg, 1973, p.   ). This establishes a necessary foundation in the treatment of traumatized, neglected, and self-abusing young adults. The Residence provides safe and caring attachments which offer a sense of membership and belonging, a structuring (as opposed to structured) environment which promotes self organization and self care, and a community where all of who they are is embraced, affirmed and validated on an ongoing basis. With The Residence as a foundation, emerging adults make deeper use of the core group program and other therapies.

This is again illustrated by April. She experienced a catharsis in, of all places, Wellness Group, where the topic was “The Healing Power of Love”. The group was discussing research findings that very sick people, even cancer patients, have better prognoses and life expectancies when they are surrounded by love and support. When she heard this, April burst into tears and, with help from the group therapist and the other residents, was able to verbalize that she felt she had killed her mother by being “such a bad girl” when her mother was dying. She wept and wept and the whole group comforted (pacified), her. The group therapist reframed her acting out as the derailing, due to the trauma of her Mother’s illness, of the natural developmental process of being an adolescent, full of life.  Let’s go on, now, to the neurobiological substrate of the work we have been describing with April.