#20. Developmental Diagnosis

Increasingly, I have been thinking of EMPs, entrenched maladaptive patterns, as having been invented by an “inner child” to solve a critical problem. I have always thought development was important, but experience has taken me further in that direction. At this point, for the majority of my therapy cases, developmental arrest has become the main paradigm for conceptualizing both the problem and the solution. I am concerned that the developmental point of view may not be emphasized enough in today’s training. A strong interest in development should be foundational for every therapist. In this post are a few principles and examples to whet the reader’s interest.

A good deal of what is written about development is still dominated by discussion of stages such as those of Freud, Piaget, and Ericson. As a clinician, I think a more useful approach is to look at the particular challenges where development can go on the rocks. Here, in addition to the pioneers, Mahler, Bowlby, Stern, and Kohut have a lot to say about specific points of difficulty. One example of a developmental challenge is this: Somewhere around age two, the blissful assumption of the one-year-old that Mom is in perfect alignment with every wish, gives way (through cognitive advances) to the shocking realization that she sometimes disagrees. Coping with this new awareness constitutes a severe challenge, where failure to develop in a healthy direction can lead to serious personality problems. Each developmental acquisition sows the seeds of the next challenge. For the clinician, being aware of these, and even better, having some empathic understanding of what the child was once facing is extremely helpful.

Are there books on development for therapists? There are several aimed towards practitioners, though they tend to be focused on normal development. Besides those, I can strongly recommend Deborah Cabaniss’ Psychodynamic Formulation, where she devotes over 40 pages to the subject. This is one book where the treatment of development is organized around major challenges, rather than traditional stages. However, one area where Cabaniss has relatively little to say is adolescence. I’ll say more about that period in the next post.

One way developmental problems can appear in adulthood is with maladaptive schemas, ways of understanding the world that may have helped at one time in one context, but that are dysfunctional the context of adult life. Often these can be treated through Memory Reconsolidation in the way that has been described several times in these posts, by activating the old schema with affect, and juxtaposing that with exposure to surprising new information, leading to change in the old schema. On the other hand, the essence of development is trying out new behaviors. What makes developmental problems hopeful is how often arrested threads can be restarted at a later time.

Developmental problems are most often the result of avoidance of emotional risks by not trying out new behaviors. Missing out on new experiences deprives the individual of breadth of skills and coping abilities. The engine of development is trying out new ways of doing things. This generally causes some anxiety and stress, but the promise of greater power and choice, along with a major instinctive drive, causes most individuals to go ahead with the new and to process the inevitable uncomfortable feelings. When positive factors are not sufficient to overcome reluctance, the person may track into a maladaptive but less stressful pattern or avoid the area all together.

An important observation is that every scary move forward is accompanied by an increase in neediness. Humans naturally require, and normally receive, extra support and encouragement at these times. Think of getting on the school bus the first time. One of the main reasons for failure to advance is an actual or perceived lack of “sponsorship” on the part of significant others.

Frequently in therapy, the need for support is transferred to the therapist. What this implies for us as therapists is that our support and encouragement may make the difference, whether our patients risk uncomfortable emotions and advance or not. Some patients in therapy feel less alone and do this on their own. The psychodynamic tradition of neutrality as well as the Rogerian client centered approach would have the clinician keep quiet and let the patient face (again) the difficult choice between growth and comfort. I suspect that good clinicians of whatever school, when they see their patient unable to find the strength to go forward, will find some way, direct or indirect, to provide support and direction. For example, in psychodynamic therapy, interpretations can serve as powerful hints to adopt a new behavior. Personally, I think it is more honest to gauge our stance according to the specifics of the situation and the patient, and, if needed, to be clear about our view. Openly communicating our position also allows us to be frank about the limits of our knowing what is best for our patient. And it allows us to be sure our goals are in sync with those of the patient, one of the well researched common factors.

Make a developmental diagnosis and plan

Once we identify in our patient an entrenched maladaptive pattern, the next step is to do what techies call “reverse engineering,” that is, assuming that the pattern is the solution to a problem, what was the problem it was intended to solve. Along the way, it is very helpful to ask oneselves at what age this pattern might have been natural and expectable. Data can include style of cognition, issues in play, or simply imagining a young person playing the part. A common and interesting example is the patient who acts destructively and seems to have no motivation to stop, in spite of doing harm to the self. The outward behavior and lack of ambivalence may be a good pattern match for “Adult Temper Tantrums,” the subject of an earlier post. In this case the treatment will differ only slightly from optimal handling of a child. The first step is stay close but “contain” the rage by finding a way to stop the destructive behavior. That is more difficult with an adult and can involve outside resources such as a hospital. Once containment is achieved, it is time to explore and process the rage.

When developmental problems arise simply from avoiding experience, the solution is simple. It is for the patient to venture into the area that was avoided, but in an adult form. One man in his 50s had never accomplished a major career objective. The job for him was to do just that in an area where his passion gave him motivation. As behavior patterns change, the avoided emotions come into view and can be processed.

In cases where the main pathology or “defense” is embodied as behavior, then the solution is to adopt new behavior. We might call this “working through” but it also looks a lot like behavior therapy. I have the impression that avoidance in the form of maladaptive behavior is more prevalent today than ever. In the Victorian era when psychotherapy was born, the emphasis was on self-control. Perhaps today’s behavioral adaptations are dominant because, in our culture, there is so much behavioral permissiveness.

Curiosity about the experience of children and young people adds immensely to the richness of our formulations and appreciation of the process of undertaking change in behavior.

Jeffery Smith MD

RESOURCES:

Psychodynamic Formulation 1st Edition. Deborah L. Cabaniss et al. 2013.

The Life Span: Human Development for Helping Professionals 5th Edition. P. Broderick & P. Blewitt. 2019.

Child Development: An Active Learning Approach 3rd Edition. Laura E. Levine & J. Munsch. 2017.

Featured photo by: Wayne Lee-Sing Unsplash

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