Core issues in the treatment of young adults

Flynn O’Malley, PhD
Program Director, Menninger Compass Program for Young Adults

Many patients have had repeated courses of psychiatric treatment in a variety of venues, including outpatient psychotherapy and medication management, multiple brief hospitalizations for stabilization and often extended treatment in residential treatment centers and programs for substance abuse and other problems. Despite competent and thoughtful treatment a subgroup of these patients either fails to make significant progress or is unable to sustain their gains. So, rather than repeat treatment that has not been effective, it is important to explore the nature of previous failures in treatment.

What are the factors that continue to drive the current pathology and/or conflict?

What is it that has prevented previous treatment attempts from being successful?

The work of trying to answer these questions leads to the identification of “core issues.” Core issues are defined as those processes and circumstances that serve to impede sustained progress in psychiatric/psychological treatment.

Jesse: A case example

Jesse, a 22-year-old college dropout, arrived at the Compass Program for young adults with a longstanding history of depression and suicidal behavior, unrelenting self-injury by cutting, interpersonal isolation and loneliness, and a great deal of pessimism following multiple attempts at treatment and numerous hospitalizations for self-injury. Jesse made it clear from the beginning that she had little hope for improvement and that she had no intention of stopping her practice of cutting herself. In fact, except for her face, hands and feet she was covered with scars which she carefully and vigilantly kept from sight with her clothing. In addition, Jesse was extraordinary self-deprecating. She referred to herself as “stupid,” although she was obviously quite bright; she presumed that others would not like her; and she blamed herself for her problems with her parents.

We needed Jesse’s help in understanding the core issues, those factors or issues that prevented her progress previously. In order to gain her cooperation and commitment to treatment, we made clear to her our intention to try to engage her, but also our recognition that this would be difficult for her and that she would likely resist our attempts. We agreed to not try to talk her out of her symptoms or make hollow promises. Honesty and authenticity in others seemed important to her, and she began to participate in discussions with her treatment team.

Early on we explored Jesse’s family relationships. She was self-reproachful about her family problems. She reported having been a major disappointment to her mother and acknowledged when she was younger her mother had been quite verbally and emotionally abusive to her. Initially she said that she accepted this as justified. In recent years the mother had abruptly and inexplicably ceased the abuse. Later, when Jesse could be more honest about her feelings she admitted that she deeply resented her mother’s past behavior toward her. Further, she resented her father’s complicity in it. She refused to address any of this with her parents for fear that her mother would be outraged and return to her abusive style. So, she took her rage out on herself by cutting.

This redirected hatred was not the only reason for Jesse’s cutting, but the discussion about her mother led to more exploration about her reasons for cutting. Understanding this behavior at a deep level was important because there is really no effective treatment for cutting without understanding its function. Jesse cut as a substitute for other intolerable feelings, in order to punish herself, and as a way of feeling numb– like using drugs or alcohol.

Jesse’s ability to collaborate and her growing confidence that our work with her might make a difference led us to a joint view of some of her core issues:

unresolved rage regarding early experiences
fears of rekindling rejection by any expression of resentment
intensely experienced hate focused on herself
embracing an extremely negative self-image, not based on any realistic view of herself, but in order to not build up any false hopes of having a life

Restarting treatment
Understanding these core issues created a sense of shared purpose and also helped the treatment team develop a more strategic treatment program for Jesse. Elements included more focused family therapy; specialized psychoeducational groups on trauma, mentalizing, self-injury and social skills; and interactivity with staff related to supporting more authentic experiencing and reporting of Jesse’s feeling states.

As time went on Jesse began to accept others’ appreciation of her; she developed a sense of a life worth living; her self-injurious behavior did not cease, but it diminished in intensity and frequency. She moved on to a more independent living situation. She remains in touch with the treatment team.