TIFT #76: Adolescent and Adult Immaturity Isn't In the DSM

tift May 23, 2023

One of the most troubling aspects of mental health treatment currently is the tendency to treat diagnoses instead of people. In the meantime we have a mental health crisis among teens and young adults where far too often, the underlying problem is developmental arrest, which isn’t even recognized as a diagnosis, let alone treated. The problem is that becoming stalled in the middle of adolescent development causes tremendous stress, which then trigger symptoms that become the focus of treatment instead of the underlying cause.

I define adulthood as “having a subjective sense of full ownership of one’s own life.” In order to get there, adolescents must give up parts of the most intense attachments of their lives. Maturation means moving from the comfort of the childhood where they can rely on parents’ or caregivers’ values, external controls, and wisdom. During that time, they must build new skills, get to know themselves, and find their own values in order to navigate a much more complex and unforgiving world.

We have we have all seen caring families spending irreplaceable resources on treatment narrowly aimed at DSM diagnoses, without it making a dent on the underlying problem. In most cases, the symptoms, which may indeed be serious, are driven by the nonconscious problem solver’s efforts to avoid the discomfort of maturation. What  symptoms might we see?

  1. Anxiety: Naturally fear is generated, most likely functioning to deter the conscious mind from undertaking the arduous job of growing.
  2. Panic:  Panic attacks out of nowhere are another sign that the nonconscious problem solver is detecting a life in danger.
  3. Depression:  The more one avoids growing, the greater the gap in relation to peers. The mountain seems too high to climb, and the result is despair and depression.
  4. Suicide:  Self-harming thoughts and even actions represent an escape route from the seemingly impossible job of growing. That doesn’t make them less dangerous, but it should point the way to addressing the underlying problem.
  5. OCD:  Symptoms of OCD may be more likely in some people than others, but the driver of these symptoms can be a mind trying to deal with an insoluble problem by focusing on something that potentially might be controlled.
  6. More extreme symptoms:  Dissociation, personality disorders, addiction, eating disorders, mania, and even psychosis can be triggered in susceptible individuals when the mind is facing what feels like a hopeless situation.

In the old days, physicians said that syphilis could mimic almost any illness of the body. In our day, immaturity can mimic or trigger just about every serious mental health diagnosis. Unfortunately, treatment aimed specifically at the diagnosis fails either because the nonconscious problem solver is determined to succeed in its mission of avoidance or because successfully eliminating one symptom only leads to a new one, ready to support the goal of avoidance.

We should not minimize serious symptoms  

This is not to say that the above symptoms can be taken lightly. The level of seriousness is an indication of the level of terror experienced by the nonconscious problem solver. That seriousness may require that we focus treatment on the symptom, at least at the beginning. But what works in the long run is to be aware of the underlying problem and to have accurate empathy for the inner self, caught between safety and the desire for growth. That may sound simple but it is not.

The nonconscious problem solver as terrorist

I hate to label an inner child in this way. It might be more accurate to picture a street kid who has seen unthinkable horrors and is deeply mistrustful, but the delicate skills required for negotiating with a terrorist shed light on how helpers and families need to navigate within a situation the young person experiences, on some level, as hopeless.

What makes the inner child look like a terrorist is that the main way to secure even a short reprieve from having to face the stress of growing is to present the grown-ups with a problem they can’t solve. Not only does that put powerful pressure on them to relieve the tension, but it also affords a way to make them feel the same helplessness the nonconscious problem solver is facing.

Why is the inner self manipulative?

Particularly when one’s early experience includes adults who don’t seem to understand, direct communication seems ineffective. How else might one communicate the urgency of finding relief from the pressure to grow? And even if the family or some of its members understand the young person’s desperation, their solution is often to urge the IP (identified patient) to “grow up.” It's hard for those who haven't experienced it to appreciate fully the level of distress. That is exactly why the inner child concludes that the job of growing is too hard, too painful, and out of reach. So, instead, the young person is left to communicate by expressing hopelessness and making threats. In the next post, I’ll discuss how to negotiate, but first, let’s look further at what makes psychological maturation so scary and hard.

The challenge of maturation

Maturation means learning and trying out new skills and having new experiences. We all recognize this as a source of stress, due largely to the possibility of failure. Failure can put us at odds with our own values or those of people we care about and can lead to negative consequences. When we fail in relation to our own internalized values, we naturally experience shame. We also imagine that others must share the same judgmental attitude. Success, too, can be stressful. It means one is expected to keep up the pressure to succeed for the rest of life. “How can I ever sustain this level of effort and stress?”

There is one scary aspect of growing that trumps all others. It’s the risk of running out of resources and crashing into abject failure. I think we are biologically programmed to size up the challenges we face and estimate whether we have the resources to surmount them. For the inner child, aware of personal limitations, running out of resources often means not having enough outside support. In a childlike mind, that means irrevocable collapse, a fate as unthinkable as death. The anticipation of needing support and finding it lacking or misguided is one of the most powerful factors working against the motivation to grow.

What I have seen over and over is that all humans facing a daunting new challenge experience a need for extra support. This applies to top level business executives, parents, young people of all ages, and, no less, those with personal challenges. When failure is experienced as unthinkable and when the right support seems not to be available, enormous stress is placed on the individual. 

As one example, one of the most common dynamics underlying schizophrenic breakdowns is the challenge of needing to grow more independent. The problem is that adding to the stress itself is the fear that extra neediness will lead to the other person engulfing the individual and smothering their fragile individuality. This is a dilemma where, either way, the consequences of not enough support or too much support are both experienced as disastrous. Facing a major and utterly insoluble problem, the mind implodes.

Why, then, does maturation usually happen?

Under healthy conditions, the payoffs for growth are huge. In a context of success, understanding and support from others is enormously satisfying. Young people get to see themselves and be seen in a newly favorable light, leading to feelings of pride along with greater freedom and choices. With benefits like those, why not take the risk? Even if the inner self is reluctant to leap, the thought of growth is intoxicating.

For this reason, relative to other pathology, immaturity is a good problem to have. Treatment is like paddling down stream. Life has great rewards for those who can recover a healthy trajectory. But first, we need to find a way to tip the balance between hope and despair.

How does one grow?

The answer is simple. It is all about behavior, taking large and small steps towards acquiring new experience and skills. The hard part is processing the uncomfortable emotions that go with facing novel situations. It would be easier if the young person were able to articulate their fear in words. That would allow them to receive the best kind of support, understanding. Too often, though, admitting to fear brings shame. Healthier young people may be more able to enlist empathic support and healthier family members more likely to give it. It is human to need support and the gold standard of support is an empathic witness, someone who understands what we feel and is not, themselves, afraid.

For too many young people, fear is expressed in other forms. It comes out as symptoms, dangerous predictions, scary medical diagnoses, and even threats. Being a supportive witness in the face of such intense expressions of distress is not easy. It does feel like dealing with a terrorist who is highly unstable and could set off catastrophic consequences. But terrorists know what they are demanding and why. The young person often has no idea of their own role in what they are experiencing. They can’t see that their symptoms and impulses are, in fact, under their own unconscious inner control. Often, the young person will hotly deny any responsibility or role in producing the symptoms and will rationalize the threats. The nonconscious problem solver hides behind diagnoses and involuntary symptoms. “I don’t want to die, but I feel so depressed that my impulses are hard to resist.”

A “cliffhanger” ending for this post…

Dear reader, I’m going to end this TIFT here because talking about how to handle this situation is complex and will require another post. How to work with immaturity will be the subject of the next TIFT, so I’ll be back in two weeks. Please stay tuned.

Jeffery Smith MD

Photo Credit: Jonathan Borba, Unsplash

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