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

 

Neuropsychoanlytic Therapeutic Technique

While there is so much more that is yet to be learned, the psycho-neurobiology of attachment has begun to teach us about the psycho-neurobiology of psychotherapy (cf., Allan Schore, 2003). Freud (1915) recognized that the work of psychotherapy is in the “basic rapport” of the affective relationship. As Gedo writes (? ), psychotherapy is a “technology of instruction” within which the relationship is the engine of learning. Neuro-psychoanalytic psychotherapy has been called essentially “a conversation between limbic systems” (Buck, 1994 p.266). The neuro-psychoanalytic model views the process of psychotherapy as the therapist’s neuro-biologically empathic response to his or her nonverbal “implicit relational knowledge” (Stern, Brucshweiler-Stern et al., 1998; in Schore, 2003, p. 53) of the patient intuited through the shifting developmental matrix (cf. Gedo and Goldberg, 1973).

The first “topic” in this conversation is at the developmental level of basic security and trust. This allows for a quieting of the danger-alerting limbic-system areas of the brain so that connectedness is more likely to occur. Research (cites?) demonstrates that increased security of attachment is associated with facilitating the development of empathy, a necessary capacity for both introspective compassion and forgiveness, which are common hurdles in this troubled group of patients.

At Yellowbrick, we often have the advantage of emerging adults coming to us for help at times of great personal and family crisis. This often includes a latent hope, openness and receptivity to new attachments, usually those of an idealizing type. These idealizing attachments offer a sense of merging protection (Kohut, 1971) as well as the motivation to identify with the admired other. This makes implicit modeling an important process within the treatment context.

The next developmental level addressed in the neuro-psychoanalytic model is self-unification. The Yellowbrick community process reinforces security, ie., down-regulation of the limbic system, and extends a sense of belonging with a unique individual identity. Opportunities are sought to affirm and validate the individual so as to strengthen the sense of a core, unified self. The community process also insists on accountability to others and the challenge of appreciating others’ experience, especially their experience of you!

Dissociation presents formidable therapeutic challenges in working psychotherapeutically with emerging adults. How can neuro-science guide technique here? It is precisely the most archaic, split off, right-brain affective experiences that the patient needs to share with the therapist but for which there are, as yet, no words. How do we access the right brain? One way experienced therapists know is through the collaborative integration of projective identification experiences. The mechanism of projective identification enables patients to share their trauma in affective form and thereby be fully known by the therapist. The neuro-biologically empathic therapist is open to recognizing that their own experience of distress and disorganization, for which there will be many rationalizations to explain otherwise, is actually the resonating right brain communication of the patient through projective identification. Interestingly, research shows that gifted empathic therapists have greater right frontal electrophysiological activation (Alpert et al., 1980) while they perceive others’ emotional states. 

Much of April’s early treatment occurred through such “conversations”. There was a rhythm in April’s treatment where moments of intimacy occurred only to be followed by misbehaviors such as drinking in flagrant violation of Yellowbrick boundaries which would put her in jeopardy of administrative discharge. Feelings among staff of betrayal and guilt as to the depth of our commitment to April swept through the community. These feelings were understood as representing dissociated aspects of April’s experience with her mother. What is significant here is the fact that these issues were not just talked about, they were lived out together among staff with April, in real time, with intense real-life consequences. At Yellowbrick, we recognize that we must engage with our patients within these implicit, nonverbal, right-brain dialogues that will be repetitively re-enacted. It is especially within these states that archaic neural networks are reactivated and can, therefore, be influenced to develop new patterns.

Accessing the right brain is a major challenge in the effort to address dissociated memory and experience. Therapeutic approaches which involve non-verbal emotional arousal, and often some form of body experience, are key. These include art studio and art therapy, dramatization, music with singing, and movement involving yoga, martial arts instruction and strength training. Mindfulness training, meditation, and guided-imagery visualizations are also therapeutic modalities that target the right brain. In fact, research demonstrates that imagining doing something activates the brain in the same areas, and to the same degree, as actually doing it (cite?).

The emergence of greater self-agency and personal responsibility also initiates the level of therapeutic intervention Gedo and Goldberg term “optimal disillusionment”. This is the third critical phase of treatment and, most often, the phase patients remain in for the duration of their intensive immersion in The Residence and Intensive Outpatient Program. The optimal disillusionment phase is when we can’t seem to do anything right; don’t have the answers; don’t say anything they didn’t already know… you’ve all been there with patients; you know how it goes. This is when our patients re-experience their parents failings and need us to, unlike their parents, admit our mistakes and own up to our failings without losing our self-valuation and mutual appreciation and positive regard. Optimal disillusionment facilitates the emergence of resilient self-regard. It frees the ideal self to become a source of guiding motivation rather than a weapon of self-condemnation.

This evolving self-development and -organization occurs, not only at the intrapsychic level; it occurs at the level of the brain. Daniel Siegel (1999) synthesizes the sum total of findings from developmental neuro-scientific research as showing that the ultimate, organizing purpose of the brain’s formation and growth throughout the lifespan is to evolve an ever more complex, integrated and higher-order representation of the self-in-relation (p.?).

 

Summary

This presentation describes the theoretical basis of a model of treatment for seriously troubled emerging adults. Arnett’s five “in between” features of emerging adulthood and Tanner’s “Re-centering” theory serve as a developmental framework. Gedo and Goldberg’s intra-psychic developmental hierarchy is utilized for understanding the fluctuating nature of the self-organization and its varying needs for different forms of therapeutic attunement and intervention. The Real-Time Treatment approach attempts to join patients at every level of their self-experience in a kind of intense therapeutic immersion. This can best occur in moments of real life in which they emerge through intense pathological re-enactments. This is where we “live with them”, therapeutically, as they confront and master the challenges of their intrapsychic development in their everyday lives. Findings from the frontier of neurobiology have profound implications for both the broad principles of treatment, and specific psychotherapeutic techniques, designed to stabilize danger-alerting brain systems, to strengthen self-unification, to access dissociated right brain experience and to increase right-left brain communication and integration.