“You’re Just Going to Have to Practice a Lot of Acceptance”: Playing with Recovery in Residential Treatment

Abstract

This paper uses mentalization theory to describe a style of intervention with adolescents in short-term, mandated residential treatment. The externalizing defenses—projection and projective identification—on which these adolescents tend to rely function as a barrier to engagement in treatment. Mentalization theory posits that these defenses originate from early experiences of unmarked, realistic mirroring. During childhood and adolescent development, individuals exposed to unmarked mirroring are more likely to deploy externalizing defenses, experienced in the mode of psychic equivalence, to regulate affect and manage interpersonal conflict. In their relationships with authority figures, this tendency can lead them to become stuck in a negative cycle of estrangement, frustration, disruptive behavior, and disciplinary intervention. When these youth are mandated into treatment, they are liable to externalize an alien-self representation of a critical and inconsiderate authority figure onto their treatment providers. Clinical material from a residential treatment setting demonstrates how encouraging playfulness with the treatment frame assists in marking these adolescents’ externalizations. Marking externalizations relaxes externalizing defenses, resulting in these youth being more open to treatment.

Notes

1.  Peter Fonagy, in a 2007 lecture on the challenge of implementing evidence-based treatments with youth and families, highlighted the self-evident problem that evidence-based treatments are less likely to work with disengaged clients: “The most severely disturbed, the most co-morbid, the individuals who miss appointments, that drop out of treatment, they will not be selected (for the treatment trial). And the problem is that if you have a treatment that is based on a skill that has to be acquired, that requires the family to attend regularly in order to learn the skill, but if they don’t attend regularly, they won’t learn the skill. So you have to have an evidence-based treatment that actually works for families who are bloody-minded and who don’t want to attend. And there are very few, in my review of the literature, evidenced based treatments for bloody-minded families” (Fonagy, 2007).

2.  Contingency and markedness also characterize Jurist’s (2006) construct of mentalized affectivity. Mentalized affectivity entails an open and curious attitude towards one’s distress while simultaneously experiencing the emotions stimulating that distress. Just as caretaker’s mirroring responses to an infant in distress are marked as representations, mentalized thoughts about one’s distress are experienced as a representation. While the content of one’s thoughts may be distressing, the act of thinking does not constitute an additional source of distress.

3.  Continued use, in this case, could be understood as an unformulated desire to maintain an attachment to a critical and disappointed authority figure—the probation officer—who could function as a host for their alien self.

4.  While in residential treatment, being away from home further contributed to the activation of their attachment systems. For adolescents with insecure attachment and mentalizing deficits, lack of physical proximity to attachment figures can be especially difficult, given their struggles to maintain psychological proximity (Fonagy et al., p. 352).

5.  I was not conducting MBT in my work in the residential program, but simply adopting a mentalizing stance to enhance my interventions.

6.  Along with three other polarities—self-other, cognitive-affective, and certainty-doubt.

7.  There is a precedent for the use of pretend play within MBT. Structured mentalizing treatments, such as MBT for families, include planned enactments—clients deliberately act out relational scenarios—which can then later be mentalized (Asen & Fonagy, 2011).

8.  Stern (2004), for instance, asserts, “The creation of internal conflict is also the creation of a sense of initiative. Desire in the absence of a conflicting alternative is nothing more than a compulsion, and compulsion negates the feeling that one is choosing one’s own life” (p. 229).

Additional information

Notes on contributors

Webb Haymaker

Webb Haymaker, LCSW, is a therapist practicing at Mazzoni Center in Philadelphia. He has completed multiple trainings in mentalization-based therapy through both the Anna Freud Centre and McLean Hospital. He received his degree in social work from Columbia University in 2004. Webb also completed a certificate in psychodynamic psychotherapy from The Psychoanalytic Center of Philadelphia in 2014.