NUMBER 579• 27 AUGUST • MILIEU
Freud writes that there are three impossible professions: Governing, Teaching, and Healing. Residential Treatment involves a complicated combination of all these. Little wonder then it is generally so poorly accomplished, so deservedly suspect a modality, often reserved for difficult patients who have failed in other forms of treatment—usually multihandicapped children or aggressively acting out adolescents. Yet, in our experience, competently conducted residential therapy is a powerful remedy and the treatment of choice for this group. 
Early proponents of this form of treatment, August Aichhorn (1925), Bruno Bettleheim (1949), and Fritz Redl (1957), along with such less central figures as A. S. Neil (1960) and Bernard Lyward (Burn, 1956), have written convincingly of the therapeutic usefulness of the child's day- to-day experiences in a well-managed milieu. The descriptions of their pioneering work are quite similar. One is struck with the unitary quality of the settings they describe, consisting of a united and dedicated staff, loyal to a charismatic Director representing certain principles of treatment. There is little discussion of modalities of treatment or departmentalized services. Mostly their books report interactions of individual children and groups of children with each other and with adults. There are many descriptions of encounters between individual children and the Director, usually at unscheduled times in the milieu, precipitated by events that could not have been predicted but which become crucial therapeutic occasions. In general, the emphasis is on the development of (frequently transference) relationships and the use of these relationships and their vicissitudes for interpretation of intrapsychic conflict. In what I call classical milieu therapy, the essential feature is the focus on the evolution of relationships in the context of which children grow as opposed to the focus on various forms of treatment applied to the child.
The gifted analysts who developed milieu therapy did not, however, have available the systematic theoretical understanding of borderline and narcissistic personality disorders which has evolved only more recently. Consequently, their form of psychoanalytic/interpretive/permissive milieu therapy had better results with individuals burdened with problems of development at the oedipal level than those children more frequently seen in residential treatment suffering from earlier occurring disturbances of object relations. Over the past years, there has been a trend away from permissiveness and interpretation in the milieu with increased attention to setting limits, behavior managing and modification, realistic consequences, and reality therapy. Some centers have abandoned the analytic point of view with varying degrees of lip service while others have preserved this approach in individual psychotherapy sessions with varying degrees of isolation from the life-space.
Meanwhile, there have been significant advances in the psychoanalytic understanding of separation-individualization (Mahler, 1975), borderline personality organization (Kernberg, 1973), and narcissistic personality disorder (Kohut, 1971; Kernberg, 1973, 1976). Insights badly needed by the early analytic pioneers in milieu treatment of antisocial children are now available. However, the current trend away from using the milieu itself for the psychotherapeutic work of activating, understanding, and modifying problematic relationships prevents our using the increased understanding of character pathology with the many patients in residential treatment no suitable for psychotherapy.
Footnote  Wintrob (1975) has discussed the differences between residential treatment, hospital treatment, and the considerations which would indicate choice of one or the other as the optimum fair of treatment for emotionally disturbed adolescents. References:
Weiner, M. S. (1978) “The Milieu of Real Relationships”, presented at bi-annual meeting of the Texas Society of Child Psychiatry, Brownwood Texas, September 1978.
Aichhorn, A. (1925), Verwahrlostse Jugend. Vienna: Internationaler Psychoanalyteches Verlog Wayward Youth. New York Viking Press, New York, 1935. Meridian Books, 1955.
Bettleheim, B., and Sylvester, E. (1949), Milieu Therapy; Indication
Burn, Michael. (1956), Mr. Lyward's Answer. London, England. Harnish Hamilton.
Kernberg, O. (1973), Borderline Personality Organization and Pathological Narcissism. New York: Aronson.
Kohut, H. (1971), The Analysis of the Self. (Psychoanalytic Study of the child. Monogr. 4). New York: International Universities Press.
Mahler, M., Pine, F., and Bergman, A. (1975), The Psychological Birth of the Human Infant. New York: Basic Books.
Neil, A. S. (1960), Summerhill. New York, N.Y.: Hart Publishing Co.
Redl, Fritz, and Wineman, David. (1957), The Aggressive Child. Glencoe, Ill.: Free Press.