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Psychoanalytic approaches to residential treatment (1)

For the next two features in our quotes series we will draw on James Whittaker's thirty-year-old contribution to Ainsworth and Fulcher's book Group Care for Children: Concepts and Issues today focusing on Bruno Bettelheim and in the next quote on Fritz Redl.

Bruno Bettelheim

In the early 1930s, a young autistic girl was brought to Sigmund Freud for treatment; Freud referred the child to his daughter, Anna, who specialized in child psychoanalysis. Anna Freud determined that the child was in too regressed a condition for psychoanalysis and that what she really needed was a totally psychoanalytically oriented living environment. She suggested a young art student couple who had a burgeoning interest in psychoanalysis and education. The young couple agreed and took the child into their family for what was to be a six-year stay. Thus, the lifelong work of a pioneer in the residential treatment of severely disturbed children, Bruno Bettelheim was launched. (Anna Freud continues her lifelong work at the Hampstead Child Therapy Clinic in London.)

The group that was to have the most profound and lasting influence on the development of milieu treatment in the United States included a large number of refugees from Nazi persecution, who came to this country from Germany and Austria in the late 1930s and early 1940s. They were strongly influenced by psychoanalysis – particularly in its applications to education – and by the power of the group association; and their collective contribution literally was the literature on milieu treatment for children from the 1940s through the 1960s. These pioneers included Bruno Bettelheim (1950, 1955, 1967, 1974; 1948, with Emmy Sylvester); Fritz Redl (1959, 1966; 1957, with David Wineman); Susanne Schulze (1951); Gisela Konopka (1946,1954); Morris Fritz Mayer (1960; 1971, with Arthur Blum); and Eva Burmeister (1960). While their adherence to Freudian concepts varied in degree and while the children with whom they worked ranged from autistic to delinquent, they all attempted to apply basic psychoanalytic principles to the child's total living environment. Of this distinguished group, two individuals – Bruno Bettelheim and Fritz Redl – stand pre-eminent. Their work spans the continuum of childhood disturbance from the solipsistic retreat of the autistic child (Bettelheim) to the acting out of the preadolescent delinquent (Redl). (No attempt will be made here to summarize the contribution of all the individuals mentioned here. The reader is urged to consult the original sources for a fuller explanation. Other contributions include Noshpitz, 1962; Goldfarb, Mintz, and Stroock, 1969; Cummings and Cummings, 1963.)

The two critical forces in the development of psychoanalytically oriented milieu treatment for children in the United States consisted of the contribution of the group already mentioned and the concurrent influence of the child guidance movement, with its emphasis on individual psychotherapy as the treatment of choice for the disturbed child and the psychiatric team as the preferred model of organization.

Brunel Bettelheim

Bettelheim's contribution to the treatment of severely disturbed children was moulded by two major life influences: psychoanalysis and his experiences as a prisoner in the Nazi concentration camps of Dachau and Buchenwald. From psychoanalysis, he gained an understanding of the elaborate unfolding of the human personality, in all its vicissitudes; from his prison experiences, he discovered the resiliency of the human spirit in overcoming the most degrading environments.

From 1944 to 1973, he was director of the University of Chicago's Sonia Shankman Orthogenic School for emotionally disturbed children – a school that continues in the mould he cast. His books and articles cover a wide-ranging sphere of interests, including the concentration camp experience, prejudice, child development, and communal child rearing. Most pertinent to our discussion here are the volumes directly based on his experiences at the Orthogenic School: Love Is Not Enough (1950), Truants from Life (1955), The Empty Fortress (1967) and A Home for the Heart (1974). Bettelheim's (1974: 5) self-appraisal of his work is as follows:

'Love Is Not Enough was meant to suggest that a consistent therapeutic philosophy, with careful thinking, planning, and acting on it, has to underpin that tender care which is necessary if one is to help a psychotic person gain mental health .... The book illustrated this principle by describing big and small events alike as they followed each other in the course of the day, in the life of those whom the institution served.

The next book, Truants from Life, contained only a short statement on the overall treatment success as of that time; the essential content consisted of four long case histories. It was hoped that these would show how – and why – the personalities of these children unfolded during the years they lived at the institution. From their quite different life histories and their various pathologies (severe delinquency, anorexia, institutionalism, and childhood psychosis), the reader could see how a unified philosophy, and an institution based on it, is helpful in restoring mental health .... Many years later, The Empty Fortress was to present a more complete discussion of the therapeutic results of the Orthogenic School for the most severe form of childhood psychosis – infantile autism. A Home for the Heart was written to make this particular form of total therapy useful to others by detailing what it consists of, and by telling the story of the staff, because they are all important for its success.'

It is difficult if not impossible to capture what is essential in these volumes, for it is the anecdotes and images that remain imprinted on the mind of the reader. For example:

Bettelheim explaining that, in order to protect his child patients, no parent was ever admitted to the school's living area (1974: 210).

Bettelheim cajoling an adolescent anorectic girl to drink a glass of milk and then securing her commitment to enter treatment (1974: 176).

Bettelheim's gentle description of the disturbed child's slow transition from dreams to waking (1950: 83).

Bettelheim's account of Paul, who progressed from 'wild critter' to university student (1955 : 153).

Bettelheim – who, it will be remembered, once described mothers of autistic children as 'feral mothers' (1959) – passing off behavioural approaches to infantile autism as reducing children to the level of 'Pavlovian dogs' (1967: 410).

Bettelheim's uncanny sense of the effect of architecture on human behaviour (1974: 130-180).

Bettelheim's detailed account of a staff member's living quarters – well organized in the northern half, disorganized in the southern half – as representative of her early unresolved years in the Deep South and her present well-integrated life in the North (1974: 299).

While there is much of value and sheer brilliance in Bettelheim's work, it is a difficult approach to put into operation. To be sure, his clinical accounts are fascinating descriptions of what disturbed behaviour is like, though in my judgment many are based on false assumptions and sheer speculation about the origins of childhood disorders. Bettelheim's purposeful isolation of parents from the treatment environment – in the face of recent studies indicating the cruciality of the transition from institution to community (Allerhand, Weber, and Haug, 1966; Taylor and Alpert, 1973) and the potential for involving parents as full participants in the treatment process (Schopler and Reichler, 1971a) – indicates a rigidity of position apparent in other areas of his model; for example, in his refusal to analyze fairly the more recent behavioural approaches to childhood psychoses. I can still recall his response at a professional meeting some years ago to a questioner who asked (quite innocently) how the recent experiments in behavioural therapy with psychotic children should be 'answered'. Bettelheim responded: 'Freud said it long ago – there will always be dogs barking at the wheels of the caravan, but the caravan rolls on.' I can remember, as a young practitioner at the time, wondering if the dogs were, in fact, trying to communicate something to the caravan driver – perhaps a loose wheel – or a road missed? On a conceptual level, his model of milieu treatment is really no model at all but, rather a collage of case vignettes, clinical observations, and descriptions of routine – fascinating to read in part, difficult to comprehend as a unified whole. In fact, there is such an inordinate amount of idiosyncrasy (and I intend no derogation here) in his work – for example, his extreme 'protection' of the milieu against visitors and parents – that one is left wondering whether his methods could be applied successfully elsewhere.

On the positive side, Bettelheim's passion for detail is reflected in every clinical account. His respect for the individual is a theme that recurs throughout his work, and his attention to the therapeutic impact of the events of daily living – the rules, the routines, the games and activities, and the struggles – helped to turn an entire mental health profession's attention from the therapy room to the life space.

On the whole, however, a reader is forced to conclude reluctantly that the essential ingredient in Bettelheim's model of milieu treatment is Bettelheim himself. His is the omnipresent force fathoming the depths of a child's behaviour; challenging a staff member to look into himself; nurturing a frightened child in the night; stoutly defending his model against all who would challenge it. Arrogant, cryptic, challenging, engaging – in writing as in person – Bettelheim and his work stand permanently intertwined: exciting to experience, impossible to duplicate. Bettelheim concluded his last book on milieu treatment expecting and welcoming challenge: 'I hope the reader will try to discover where I have gone wrong, but not be satisfied merely by registering a negative, but try to understand why and how it all could be done better. If he does this, he will have paid the author the highest compliment possible' (1974: 14). That is the challenge, the great stimulus, which Bettelheim's work presents: to find a better way. Whatever eventually becomes of his ideas, Bettelheim will always be viewed as a pioneering force in the development of milieu treatment.

Allerhand, M. E., Weber, R, and Haug, M. (1966) Adaptation and Adaptability: The Bellefaire Follow-up Study. New York: Child Welfare League of America.

Bettelheim, B. (1950) Love Is Not Enough. New York: Free Press.

Bettelheim, B. (1955) Truants from Life. New York: Free Press.

Bettelheim, B. (1967) The Empty Fortress. New York: Free Press.

Bettelheim, B. (1974) A Home for the Heart. New York: Knopf.

Bettelheim, B. & Sylvester, E. (1948) A Therapeutic Milieu. American Journal of Orthopsychiatry 18 (2): 191-206. Also in H. W. Polsky, D. S. Claster & C. Goldberg (Eds) (1970) Social System Perspectives in Residential Institutions. East Lansing: Michigan State University Press.

Burmeister, E. (1960) The Professional Houseparent. New York: Columbia University Press.

Cuings, J. & Cuings, E. (1963) Ego and Milieu. New York: Atherton Press.

Goldfarb, W., Mintz, I. & Stroock, K. W. (1969) A Time To Heal. New York: International Universities Press.

Konopka, G. (1946) Therapeutic Group Work with Children. Minneapolis: University of Minnesota Press.

Konopka, G. (1954) Group Work in the Institution. New York: Association Press.

Kozloff, M. A. (1975) Reaching the Autistic Child in a Parent Training Program. Champaign, Illinois: Research Press.

Mayer, M. F. (1960) The Parental Figures in Residential Treatment. Social Service Review 34 (3): 273-85.

Mayer, M. F. & Blum, A. (Eds) (1971) Healing Through Living: A Symposium on Residential Treatment. Springfield, Illinois: Charles C. Thomas.

Noshpitz, J. D. (1962) Notes on the Theory of Residential Treatment. Journal of American Academy of Child Psychiatry 1 (2): 284-96.

Redl, F. (1966) When We Deal with Children. New York: Free Press.

Redl, F. & Wattenberg, M. W. (1959) Mental Hygiene in Teaching. New York: Harcourt Brace Jovanovich.

Redl, F. & Wineman, D. (1957) The Aggressive Child. New York: Free Press.

Repucci, N. D. & Saunders, J. T. (1974) Social Psychology of Behaviour Modification: Problems of Implementation in Natural Settings. American Psychologist 29: 649-660.

Schopler, E. & Reichler, R.]. (1971a) Parents as Cotherapists in the Treatment of Psychotic Children. Journal of Autism and Childhood Schizophrenia 1 (1): 87-102.

Schulze, S. (Ed.) (1951) Creative Group Living in a Children's Institution. New York: Association Press.

Stephenson, R. M. & Scarpitti, F. R. (1974) Group Interaction as Therapy: The Use of the Small Group in Corrections. Westport, Connecticut: Greenwood Press.

Taylor, D. A. & Alpert, S. W. (1973) Continuity and Support Following Residential Treatment. New York: Child Welfare League of America.

Extract from Whittaker, J. Major approaches to residential treatment. Chapter in Ainsworth, F. and Fulcher, L.C. (eds.) (1981). Group Care for Children: Concepts and Issues. Tavistock Publications, London and New York.

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