An Unchanged Mind: The Problem of Immaturity in Adolescence
Dr. John A. McKinnon

I was trained sufficiently long ago to find it congenial, as a psychiatrist, to think of teenagers' problems in a developmental way. Thirty years ago when I was a resident at Yale, I was taught to think of adolescence as a spectacular noisy, sexy, amusing and sometimes precarious transition between the childhood and adult stages in the human life cycle. In this education Erik Erikson was a gruff avuncular presence—a blue-eyed, silver-haired professor who was, at that time, an intellectual mentor whose account of the "Eight Ages of Man" topped the reading lists in our seminars.

From a developmental point of view adolescence is but one stage—but a key step—in a sequential progress from birth to death. This portentous stage is an integral part of the larger life span, and so what happens in adolescence is firmly connected to what came before and to what will follow. This being so, a disrupted childhood makes adolescence less smooth, less secure and less likely to accomplish what needs to be accomplished to prepare for adult life. A botched adolescence can permanently wreck the infrastructure of adult character. Between childhood and adulthood the adolescent "identity crisis" is a prolonged moment of truth.

The developmental point of view, of course, was not and is not the only legitimate psychiatric perspective upon human behavior. There are other useful ways to describe what happens in the brains and minds of young players who strut and fret their hours upon that stage in the life cycle. Yale's department of psychiatry, in those days, was divided among these various clinical and research perspectives—and was, for this variety, a better place to train.

There were in New Haven, at that time, a psychoanalytic institute whose world-renowned scholars debated psychological meta-theory and excitedly contemplated the laws surrounding child custody and innovations in linguistics; a public mental health center framed on social systems theory; nationally funded laboratories for biochemical bench research; a famous child study center; hospital clinical research units doing controlled studies of drug efficacy; a veterans' hospital, where Vietnam vets struggled with the psychological after-shocks of combat; and an adolescent hospital whose young inmates were floridly psychotic or locked into an intractable proclivity for anti-social delinquency.

From this smorgasbord I chose to train to do psychotherapy. I had been an English major in college, had written about Wallace Stevens' idea that human beings shaped the mental world they inhabited by means of acts of the imagination, and so I was drawn to all the ways—sensible, sane and otherwise—that human beings tried to imagine a world in which they could find solace and live vigorous lives. A psychiatric resident with my clinical ambitions, in those days, got assigned to the Yale Psychiatric Institute, the university's remarkable hospital for profoundly disturbed teenagers. This peculiar institute, whose young patients were referred from across the nation, was one of Yale's two primary training sites for therapists. There I spent my training years learning to foster relationships and to understand and help a motley collection of profoundly disturbed teenagers, who were—as we said among ourselves—either sad or mad or bad, or all of the above.

The variety among the university's psychiatric teaching units seemed only an advantage, in those days. After all, a resident who took an interest in one aspect of mind was still expected to learn all the others. A bench researcher still worked the ER when on call, caring for hallucinating, suicidal, confused or inebriated men and women who came in out of the night. A psychotherapist still had to be competent with medications. The director of the Yale Child Study Center did research on the pharmacology of Tourette's Syndrome, but also had trained as a psychoanalyst. The was the ideal, in those days, the Renaissance man, the well-rounded clinician capable of thinking about human beings in all of those disparate theoretical ways. It was understood in those days that some human problems were best assayed in psychological terms, others in biochemical terms, others as organizational, economic or political problems. In that exhilarating tower of Babel with its profusion of different kinds of diction, what I did not foresee was a radical splintering of my profession and a coming mortal struggle—fought in economic terms, in the end—as to which clinical perspective would prevail at the expense of the others. I should have seen this coming. There were plenty of signs. In the same month I started as a new resident at the YPI, for example, the entire forty-bed hospital—professional staff, grumpy confused patients, med students and residents, nurses, consulting psychoanalysts, battered furniture, athletic equipage, pots and pans, pantry supplies, pharmacy, even the ash trays (for in those days teenagers and staff both were permitted to smoke)—moved out of Yale Medical School's headquarters on Cedar Street. For years that venerable psychiatric hospital had been located down the hall from the Dean's office, but now its famous clinical service, where developmental and object-relations understandings of schizophrenia and adolescent delinquency had been pioneered, was relocated to a rented dormitory four miles away on the campus of Albertus Magnus college. If I then considered the meaning of this exodus, I probably saw it only as a paltry squabble over university real estate—which no doubt in part it was.

But this exile was more than a shuffling of departmental office space and furniture. It was a portent of what would soon happen in the professions of psychiatry and psychology. For that expulsion was a symbolic displacement, also, which anticipated the banishment of psychoanalysis, the demotion of developmental psychiatry, and the loss of prestige of the "talking" therapies. A few short years after I trained at Yale the diagnostic nomenclature would again be revised. A psychodynamic nosology, revised in 1973, was to be further displaced in 1982 by descriptive syndrome diagnosis. Innovations in neurotransmitter psychopharmacology called for a more objective nosology, and so the psychoanalytic model of mind, with its preoccupation with semantics, its mental model of conflict, got pushed aside. Out went the "neurosis"—and in came the "disorder." Out would go psychotherapy, in coming years, and in would come the clinical psychiatry of the synapse: prescription pad, brief office visit and pills.

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In this professional turmoil after I departed New Haven's leafy streets, I have struggled to find a dignified, effective context for clinical practice. In the end, with a little help from my friends, I have had to imagine and create my own—a story I tell at the opening of this book. In the meantime I felt a little like Daniel Boone lighting out for the frontier when I saw the encroaching cooking fires of new neighbors and sensed the loss of elbow-room. At University of California in San Francisco, where I took my first job, I was a well-supported and encouraged young professor and teacher in a fine medical school, helping direct the training of young psychiatrists and psychologists, happily managing an ambulatory clinic in an urban VA medical center—until abruptly, as it seemed to me, my boss, the department's chairman, a famous psychoanalyst, got replaced by a bench researcher whose expertise was all about the biochemistry of slime mold. I then moved to Texas, where I helped to start a new adolescent and adult hospital—until I was so offended by intrusive "managed care" that my practice no longer seemed to be my own. In Montana I was, for a decade, a small-town shrink in private hospital and outpatient practice—until . . . well, I will tell you about it in chapter one.

* * *

What has not changed in me, in thirty years, has been an abiding curiosity about teenagers and their troubles. What also has not changed in three decades has been a young person's need for adult help to grow up straight and strong. Adolescents regularly need their parents—and other adults who inhabit the village it takes to raise a teenager. When they get into serious trouble teenagers still need a psychiatrist who understands their troubles and can talk straight with them. Moreover, despite the wonders of a modern understanding of the synapse, neuro-scientific discoveries have not replaced the skills of deft parenting. No pill substitutes for a mother or father. Nor will pills ever replace the psychiatric conversation that troubled teenagers need when they get stuck, and cannot grow up. The skills of parents and psychotherapists are congruent, closely related. And treating developmental troubles in children and adolescents, I will argue, is a parental task. Helping kids to grow up is, after all, what parents do.

After these introductory remarks it will not surprise you to learn that, in this book, I will urge that a developmental point of view is necessary for parents—and for psychiatrists, psychologists and teachers—if they are to make sense of the many troubles of many troubled teenagers. For immaturity often is the explanation. Not that delayed maturation is always the problem. Nor is it that immaturity is the only problem that can disrupt the life and frustrate the potential of a modern teenager. Yet, much more often than contemporary clinicians seem to realize, a global breakdown in adolescence—with repetitive failures at school, at home and among social peers—is best explained not as an acute mental disorder that calls for a pill, but as a disrupted maturation that calls for sustained parental intervention of a very different kind.

Kalispell, Montana
29 February 2008

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