Two-Person Relational Psychotherapy: High School Age Adolescents

, Jeffrey R. Strawn² and Ernest V. Pedapati³

(1)

Division of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

(2)

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA

(3)

Division of Psychiatry and Child Psychiatry Division of Child Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

Change is the law of life. And those who look only to the past or present are certain to miss the future.

—John F. Kennedy

Adolescence is a developmental period of life that commences with the onset of puberty and artificially ends with adulthood. The twenty-first century saw substantial advances in understanding the biological, psychological, and sociological aspects of adolescent development. Moreover, accumulating data support the notion that adolescent behavior cannot be reduced to purely psychological or biological phenomena. Rather, an understanding of any aspect of adolescence is best derived from an appreciation of biology and psychology and their respective interfaces. For example, imaging studies of adolescent brains confirm aspects of fluidity in decision making and a number of other cognitive capacities (Giedd et al. 1999). Giedd explains that during adolescence, the area of the brain responsible for organization, planning, and strategizing is not fully developed, as the gray matter continues to thicken. In turn, these neuroanatomic changes likely occur in tandem with changes in the implicit relational memory processes. Further, the scientific literature confirms the belief that adolescence is a period of inordinate risk taking and complexities in decision-making processes (Reyna and Farley 2006).

Thus, the psychodynamic understanding of adolescence has evolved considerably over the last century, from a foundation rooted in Freud’s structural and drive theories to a more contemporary understanding that has been informed by temperament, attachment, and relational theories. Adolescence has been reconceptualized from a period of instability and psychological turmoil to a period in which most adolescents successfully regulate the shifts in affective states and negotiate the complexities of the environment, developing the capacity for intimacy and stable interpersonal relationships (Delgado et al. 2012).

In this chapter, we provide the reader a case example of an adolescent receiving treatment in which a contemporary two-person relational psychotherapeutic approach is used, with attention given to the patient’s and her mother’s temperament, cognitive and affective flexibility, and internal working models of attachment, all within the context of intersubjectivity . A detailed description of the work that transpired is provided with additional comments about how the intersubjective experience in the here and now guided the psychotherapist interventions during the process. We also provide the reader with a view of the case from a traditional one-person model to serve as a broad review of the main differences that exist between both theoretical approaches.

As a reminder, much of what transpires that promotes changes and moves along the process occurs at an implicit nonverbal level and is strongly influenced by the patient’s and psychotherapist’s tone of voice, posture, and nonverbal expressions in the here-and-now moments.

13.1 Psychodynamic Psychotherapy in High School Age Adolescents

Contemporary psychodynamic understanding of the adolescent is strongly influenced by attachment theory and intersubjectivity, the interaction between implicit nonconscious relational experiences of the self and others. The adolescent’s developmental task is to successfully regulate the shifts in affective states in order to develop the capacity for intimate and stable interpersonal relationships.

The reasons for which adolescents seek help are typically due to emotional or behavioral problems. The adolescent psychiatrist or clinician will benefit from a careful use of the contemporary diagnostic interview (CDI, Chap. 8) in order to understand the adolescent’s unique attributes—temperament, cognition, cognitive flexibilities, and internal working models of attachment—within the context of the environment in which they live in, which includes family and culture. Furthermore, the contemporary psychodynamic theory has helped define periods of healthy turmoil, with episodic moments of intense anger and isolation, as well as unhealthy turmoil as a result of adolescent psychopathology, with persistent patterns of acting out, self-defeating behavior, academic failure, substance abuse, and promiscuity.

13.2 Michelle

History of Present Illness

Michelle, a 16-year-old Caucasian female, was brought by her mother with a specific request to help her daughter cope with the sad feelings due to the breakup of a 2-year, long-distance relationship with a 17-year-old female peer—whom she never met in person. Since the breakup, Michelle spent much of her time in her room crying and requested that her mother “find someone I can talk to. It is not right to feel this bad.” After the breakup, she had begun to struggle at school, and her mother found her to be more “moody at home.”

Michelle ostensibly was happy during the 2-year relationship, and the couple had planned a summer trip to meet. The relationship was her first same-sex experience. She had earlier dated a male adolescent, although she reported that she found him “boring.”

Past and Family History

Michelle was the product of an unplanned, uncomplicated full-term pregnancy when her mother was 16 years old. During the pregnancy, her mother lived with her parents, who were described as being unsupportive of the circumstances. After Michelle’s birth, due to the increased conflict with her parents, Michelle’s mother moved in with her daughter’s 17-year-old father, who lived at his parents’ home.

Michelle achieved her developmental milestones on time and was overall a healthy child. At the age of 3, she was sent to live with her maternal grandparents, as both of her parents were unable to care for her and had begun to use drugs heavily.

Michelle’s grandparents proved to be very supportive of her care and covered the costs for her education in private Catholic schools. She remained with her maternal grandparents until she was 13 years old, at which point her mother asked that she once again live with her. Her mother had completed her substance abuse treatment, had remarried, and felt better able to care for Michelle. Michelle’s mother reported having a history of bipolar disorder with several hospitalizations as an adolescent and as a young adult. She was no longer in treatment, stating she had mastered the illness and was in the process of finishing nursing school.

Throughout her early childhood, Michelle had a conflicted relationship with her mother, who would visit Michelle on weekends—although inconsistently—and would generally use Michelle as her supportive friend. Her father would visit her inconsistently, and when she was 10 years old, he stopped all communication without explanation, for which she was angry: “I clearly have issues with abandonment.”

According to her mother, Michelle’s maternal grandparents, extended family, and teachers described Michelle as an easy, jovial, and intelligent adolescent. At the time of the evaluation, Michelle was an honors student. She had hoped to pursue a career in soccer, but due to a sport injury, she was in constant pain and required biweekly physical therapy, and she was told that she likely would not be able to return to competitive sports.

Michelle was living with her 33-year-old mother, 38-year-old stepfather, and two half-sisters, ages 3 and 1 year old.

Contemporary Case Formulation Following Use of the CDI: Michelle

Michelle: A 16-year-old Caucasian female who presents with new functional impairment timed with the breakup of a 2-year relationship with a female peer

Internal working models of attachment (IWMA): Ambivalent/anxious

Temperament: Mixed—predominantly easy/flexible with some feisty/difficult

Cognition: Above average (see developmental milestones Appendix A)

Cognitive flexibility: High/adequate

Formal psychiatric disorder: Symptoms of dysthymia, although did not meet full DSM-5 criteria

Treatment recommendation: Two-person relational psychotherapy to help her develop new and more adaptive models of interaction with others with improved affect regulatory functions

Contemporary Case Formulation Following Use of the CDI: Mother

Michelle’s mother: A 33-year-old Caucasian female who presents with functional impairment in regard to providing the affective attunement needed by her 16-, 3-, and 1-year-old daughters

Internal working models of attachment (IWMA): Avoidant/dismissive

Temperament: Mixed—predominantly feisty/difficult with some easy/flexible

Cognition: Average

Cognitive flexibility: Average to limited

Formal psychiatric disorder: History of mood disorder and relational problems that, although did not meet full criteria, are within the realm of cluster B traits, predominantly borderline

Treatment recommendation: Participation in her daughter’s psychotherapeutic process; suggest her own individual psychotherapy to help her develop new and more adaptive models of interaction with her daughter.

13.3 Case Conceptualization from a Traditional One-Person Model

In conceptualizing this case from the lens of a traditional one-person model, the formulation may be seen from several angles, depending on whether it is viewed from a drive theory, ego psychology, object relations, self-psychology perspective, or in a pluralistic manner—a combination of theories but without a clear delineation among them in spite of their differences.

In the traditional psychoanalytic literature, abandonment by parents in early childhood is considered to have a significant negative impact on the intrapsychic psychological processes of the child. Abandonment from parents contributes to a child making use of maladaptive ego defensive mechanisms to cope with the realities of the situation. They generally deny the reality of their abandonment , identify with the parental internalizations (e.g., being abandoned for being a bad child), or create a false sense of self to prevent closeness with others in order to prevent further abandonments. The patient generally presents to psychotherapy for the treatment of poor self-esteem and feelings of guilt for the abandonment.

Further, in the case of Michelle, the diagnostic formulation of her problems may be viewed at many different levels. For example, her parents were adolescents when she was born, and the abandonment occurred at a young age. This clearly had significant negative repercussions in her psychosexual development. Her environment was not conducive to providing the necessary warmth and mirroring, and as a young child she learned to make use of immature ego defense mechanisms to prevent feelings of loneliness. She likely developed narcissistic character traits to manage feelings of despair. The developmental interference in her growth further led to unresolved oedipal conflicts due to the abandonment by both her mother and her father, which did not allow for a successful work through the developmental tasks of this phase. The repercussions from her abandonment during this phase can be surmised by repressing her anger toward her father and wishes for reunion with an available mother (object representation). Thus, she had significant problems negotiating the second individuation process of adolescence.

As a note, Michelle’s struggles began at the same age that her mother gave birth to her. This can be considered a generational unconscious repetition of the problems of adolescent individuation. Additionally, it may lend to be viewed from the perspective of generational family issues, typical in family therapy schools.

In a traditional one-person psychotherapeutic model, the treatment of an adolescent is best achieved by the psychotherapist’s empathy and self-object mirroring to help the patient feel safe and improve the therapeutic alliance. In this case, there may be the need for occasional moments of neutrality if Michelle’s projection of negative affect occurred, which would allow for the transference to develop and later be amenable to interpretation. The psychotherapist will likely be initially experienced as the helpful father or mother object, noted by an increase in positive identifications and idealizations of the psychotherapist. Further, by maintaining some neutrality and not gratifying Michelle’s wishes for closeness, the psychotherapist can help Michelle work through her anger toward her parents in the transference to the psychotherapist.

Regarding Michelle’s mother, in the traditional one-person model, the psychotherapist may provide regular educational sessions to help Michelle’s mother understand her daughter psychologically and to support the psychotherapeutic process. Michelle’s mother may have initially been thought of as struggling with unconsciously not wanting to be reminded of the loss of her own loved object (her daughter’s father), akin to parents with “ghosts” in the nursery (Fraiberg et al. 1975), which interfere with their ability to successfully parent and help the child develop adaptive ego functions. Additionally, in the traditional one-person model, Michelle’s mother’s phone call to the psychotherapist (see below) may have represented jealousy of her daughter’s biweekly sessions with the psychotherapist, hoping to also have a relationship with the psychotherapist to feel validated as a good mother.

13.4 Two-Person Relational Psychodynamic Psychotherapy in High School Age Adolescents

Two-person relational psychotherapy has evolved from the traditional one-person models of psychoanalytic treatment for adolescents. What began as a journey of discovery of the adolescent’s unconscious conflicts has now broadened to be an asymmetrical interaction between patient and psychotherapist based on mutuality that promotes the cocreation of more adaptive experiences for the patient in the form of a new emotional experience, which is then stored in nondeclarative memory systems. The asymmetry refers to the psychotherapist’s personal healthy attributes, relative to the patient’s maladaptive attributes. The asymmetry allows the psychotherapist to be guided by the intersubjective experiences provided by the patient in the here-and-now moments. The relational psychotherapist makes careful use of timed enactments and self-disclosures to move along the process in what are called moments of meeting. Herein, together, the patient and psychotherapist cocreate new and corrective emotional experiences . We note that at times self-disclosures and enactments occur unknowingly to the psychotherapist and its presence is revealed by the patient.

Allowing Subjectivities to Meet

Context

The child and adolescent psychiatrist went to the waiting room to greet Michelle (who had requested the appointment) and her mother, at which point Michelle quickly got up, approached the clinician, and pleasantly stated, “My mother wants to talk to you without me. I am OK with that; she can take the first half of the appointment.” Her mother remained seated and silent, implicitly waiting for the interaction between Michelle and the clinician to provide her the information she needed about how the interaction was to proceed.

Child and Adolescent Psychiatrist

In knowing that both had clearly prepared for this moment and were asking for something that seemed reasonable, rather than challenging the patient and her mother, he agreed to accept their request and learn more about the implicit relational style. He made note about his intersubjective feeling: “I feel both of you are already attempting to control the interaction, and it seems something so natural to both. It must be sad not knowing how you influence others to feel about you and unrealistically expect them to understand you.” The clinician intersubjectively experienced Michelle as assertive and comfortable with the caretaking role she had taken, compared to the passive role her mother took.

Mother

The clinician brought Michelle’s mother to his office and attempted to engage her by pleasantly sharing the charming attributes of her 3- and 1-year-old girls, who were in a stroller (a technique common in a contemporary diagnostic interview, see Chap. 8). She did not address the comments and rather seemed pressured in wanting to let the clinician know the facts about her daughter’s problems or at least how she saw them. She opened the conversation by stating, “I am so glad to share my side of the story first, so you can have a good picture.” She felt guilty for not being available to her daughter during the first 13 years of her life and was now happy that Michelle was living with her—“She knows that I always cared about her. I just couldn’t do it until now.” In contrast, in her next comment she did not demonstrate any real happiness in having Michelle live with her, “The problem is that she is just like her father; he was very manipulative and vindictive,” and was worried because she felt her daughter was demonstrating the same tendencies. She believed that her daughter did not appreciate “that I am in her life now. She should learn that she needs to open up to me, like most daughters do, so I can help her emotionally.” She openly stated that she hoped for the clinician to help Michelle learn to open up with her and to understand that the relationship she had with her girlfriend was unhealthy and that she should get over it.

Intersubjective: Michelle’s Mother

The clinician had a mixed set of intersubjective experiences. Initially, Michelle’s mother was experienced as likeable and caring about her daughter’s future in agreeing to seek help for her. Nevertheless, within a few minutes, the clinician experienced the contradiction of his emotions in the here and now. Intersubjectively, he thought, “I like her for trying to help her daughter, although I feel I am speaking with a teenager.” She seemed narrow-minded regarding the complexities about Michelle’s life experiences—growing up without having her mother available for many years—and was comparing Michelle to her father’s negative characteristics, even though Michelle excelled in school and asked for treatment. Further, he was saddened that the two young children in the stroller were actively seeking for some social referencing during the session, which he provided in an obvious manner, hoping that their mother would take over, which she did not during the entirety of the 30-min session. She did not seem to know how to soothe and reference back to them, clearly having problems in knowing how to be a good enough mother.

Michelle

Upon entering the office, Michelle seemed polite and jovial, and she pleasantly stated, “Finally I have somebody to talk to. I bet you wonder how I can live with my mother, who doesn’t know how to be motherly, even to my little sisters.” She added, “I thought it would be helpful for you to meet my mother first. Most people have a hard time believing me when I say she is not a good mother, even though she thinks she is. Her not being part of my life until the last 3 years just confirms that she doesn’t know me.”

She was articulate throughout the session and shared that she now understood why people feel devastated after breaking up with a loved one. She accused her girlfriend of being a shallow person for not believing that a long-distance relationship—several states apart in this case—would work. She added, “We had two great years; we used a webcam when we slept. It was nice to get up and have someone that loves you to be there.” She was certain that her emotionally charged comments pushed her girlfriend away, whom had begun to date an adolescent male.

Intersubjective: Michelle

The clinician had a mixed set of intersubjective experiences when talking with Michelle. Although she was a very likable adolescent, he noted that the experience felt as if he were talking to a young adult woman. He notices intersubjective feelings of being proud of her for having survived her life without knowing where her mother was and how brave she was in letting her mother enter her life in the last 3 years. Nevertheless, although he felt that she seemed resilient and knew about her mother’s limitations, “she doesn’t know how to be motherly,” she also seemed to have compartmentalized her feelings of loneliness. As the clinician listened, he intersubjectively felt, “Why does this adolescent not talk about friends? Why is she sharing matters as if we were distant friends catching up?” as in her narrative there was an absence of any reference to close peers who could have provided some support to her during her life and much more during the painful breakup.

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