The Ward and the Womb: An Integrated Therapeutic Approach for Treatment Resistant Adolescents

ABSTRACT

In mental health settings, we often meet traumatized and volatile youth who resist treatment and do not respond to engagement attempts. For such patients, the treatment refusal may be a representation of their level of personality organization; it can represent difficulties to relate to others, to regulate affective experiences, and to integrate different self-states. Using a case study of a treatment resistant adolescent in residential care, I discuss the limitations of engagement techniques with patients at the lower end of personality organization and argue that engaging “difficult to treat” adolescents requires a clinical shift from the therapeutic encounter to the development of a system-based “holding” environment. I present a modified intervention model that integrates psychodynamic formulation of personality development with process-oriented systemic work. The model described emphasizes the role of the therapist as the initiator and facilitator, helping to construct a coherent and attuned environment within the residential care system. Through case vignettes, I provide examples for the clinical shift from the therapeutic encounter to the environment of the ward and demonstrate how developing a holding environment can overcome engagement barriers and support the development of the patient’s ego capacities, sense of self, and object relations.

Acknowledgments

The name and details of the discussed patient were changed to protect her confidentiality. I want to thank F., the clinical director of the residential care program, for supporting me throughout my work on the case, and the staff at the ward for their devotion for Melanie and willingness to share their difficulties and concerns. I would also like to thank Jonathan H. Slavin, Ph.D., for his thoughtful comments on several drafts of this paper.

Disclosure statement

No potential conflict of interest was reported by the author.