Psychoanalytic Approaches to Residential Treatment
For these last two features in our Quotes series we have drawn on James Whittaker's thirty-year-old contribution to Ainsworth and Fulcher's book Group Care fore Children: Concepts and Issues — the previous focusing on Bruno Bettelheim and in this Quote on Fritz Redl.
What the contribution of Bruno Bettelheim represents for the psychotic child, the work of Fritz Redl represents for the delinquent. A psychologist and psychoanalyst, Redl came to the United States from Vienna in 1936, strongly influenced by Freud and by the work of August Aichorn (1935) with delinquent adolescents. He was keenly interested in the interplay between individual and group dynamics and in the group's potential as a medium for changing delinquent behaviour. Redl settled in Detroit, where he was founder and director of the Detroit Group Project and Pioneer House - a small, community-based residential program for hyperaggressive, acting-out preadolescents. He also directed a special residential unit at the National Institute of Mental Health in Bethesda, served as consultant to several of the larger psychiatric children's hospitals in the country, lectured on an international scale, and was a professor of behavioural sciences at Wayne State University. His writings span nearly fifty years and cover the fields of child mental health, special education, group dynamic, and milieu treatment for behaviour-disordered children. His two books on the Pioneer House project with David Wineman — Children Who Hate and Controls from Within (published as a single volume in 1957) — stand as singular classics in the literature of milieu treatment. His other books include Mental Hygiene in Teaching, with M. Wattenberg (1959), and When We Deal with Children (1966). Two of Redl's contributions to the theory of mileu treatment are his analysis of the essential ingredients in a therapeutic milieu and his development of the life-space interview.
In a brilliant synthesis of organizational, group, and individual dynamics, Redl provided the field of child mental health in the 1950s with a conceptual screen for viewing all the diverse elements in a therapeutic milieu. He also developed the various 'tools' to be used in changing children's behaviour. Central here was his concept of the lifespace interview (LSI), a set of action-based interview strategies designed to help child care workers deal with real-life problems of children when and where they occur. Life space refers to the total physical, social, psychological, and cultural 'space' surrounding an individual at any given point in time. The focus (and often the locus) of the interviews is the child's own natural milieu, and most deal with specific behavioural incidents. The strategies include 'emotional first aid' — techniques designed to help a child weather a behavioural storm and return to the life space; and techniques for exploring a more chronic pattern of behaviour in relation to the child's overall treatment goals. Basically, the life-space interview was developed for two reasons: (1) the inadequacy of the reality-detached, fifty-minute therapy session as a device for dealing with the problems of behaviour disordered children living away from home; and (2) the need for a specialized set of techniques for child care workers and houseparents to provide what Redl called 'therapy on the hoof'. (The life-space interview concept has been expanded and applied to a variety of educational and treatment settings. See Long, Morse, and Newman, 1971 :442-52, 473-91.)
The impact of Redl's work is difficult to assess. Though it opened its doors over thirty years ago, Pioneer House foreshadowed many of the innovations in community-based child treatment: low visibility, strong community ties, focus on teaching specific behavioural skills, and involvement of child care staff as on-line therapists (Redl and Wineman, 1957). I have suggested elsewhere (Whittaker, 1970a) several possible reasons why Redl's model was not widely adopted - generally having to do with its 'folksy' terminology (some of the techniques are labelled 'massaging numb value areas', 'new tool salesmanship', 'draining frustration acidity'), unlikely to appeal to the Scientifically minded professional, and a falsely imputed view of the model as overpermissive. (For Redl's thoughts on this issue, see Redl, 1966: 355-78.)
A third and more plausible reason has to do with the traditional structure of institutional facilities for emotionally disturbed children in this country. Many residential facilities are organized more around the needs of the professional groups who run them than around the needs of the children they are designed to serve. Thus, we have a 'medical model' of residential treatment, which is usually just an extension of the psychiatric team from child guidance. In this system, child care workers are used to care for and often live with the children, but their function is not usually seen as 'treatment' per se. A variation on the medical model is the 'social work' model of residential treatment. Here the same kind of role rigidity is maintained, despite a shift in the status hierarchy. Typically, psychiatric social workers are responsible for the treatment of the children — usually in office interviews — though they may make use of psychiatric and psychological consultants. In the period 1950-1970, numerous specialities were elevated to professional status; but in some ways this practice worked to the detriment rather than the benefit of the children in care. In the course of a single week's time, the disturbed child might be expected to see his psychotherapist, group therapist, family caseworker, occupational therapist, recreational therapist, music therapist — and so on. The life-space model of treatment rejected such specific role definitions in favour of a far more generic approach. It was a model of treatment developed from the problems posed by the children in care and not from the needs of any single professional group. Herein probably lies a reason why the model has been adopted so infrequently: it wreaks havoc with the traditional notions of 'who does what' in a residential treatment centre. In addition, the life-space model contains a built-in threat to the therapist who is accustomed to working only in the sanctity of his or her office and in the context of the fifty-minute hour. Dealing with problems in the life space is akin to working in a fishbowl: both successes and failures are clearly visible to all.
Despite these and other problems in adaptability, Redl's work has contributed significantly to the theoretical development of milieu treatment in two important areas. His was the first and -at the time- most sophisticated attempt to provide a taxonomy of aggressive behaviour in children. For Redl, there never was simply an 'aggressive child'; instead, there was a complex interplay of personality facts and group dynamics located in a particular space-time context that combined to produce a specific behavioural result. In many ways, his work foreshadowed the efforts of Wahler, Patterson and other applied behaviour analysts in identifying the structural aspects of deviant child behaviour (Wahler, House, and Stambaugh, 1976; Patterson et al., 1975). Second, his model stood nearly alone for many years as a testimony to the belief that success in milieu treatment is directly related to the ability of programs to incorporate child care workers as primary agents of therapy. While many clinicians paid lip service to the importance of child care staff, Redl built a model of treatment around them. He developed specific techniques — such as the life-space interview — for managing children's behaviour as well as for teaching alternatives. He recognized the power of the peer group as a potential force for positive change and developed a conceptual scheme for observing and intervening with group behaviour. His model recognized the importance of activities in a therapeutic milieu, and he helped to elevate program activities to the status of a 'full-fledged therapeutic tool'. His notions on the use of punishment and on preadolescents — contained in works written in the 1940s and early 1950s — remain valuable today.
In my opinion, Redl's work retains its viability because many of his concepts can exist apart from the psychoanalytic foundations on which they were originally conceived. Much of what Redl had to say about the techniques for the management of surface behaviour in children can be translated without damage to a social learning framework (Redl and Wineman, 1957: 395-486). The life-space interview material, although procedurally primitive, continues to provide a useful framework for organizing therapeutic conversations with children and can serve as an adjunct to individual behavioural programs designed to build new behavioural repertoires or extinguish old ones. Perhaps more than any other single theoretician of his time, he contributed to our understanding of what actually makes a milieu work.
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.
Aichorn, A. (1935) Wayward Youth. New York:
Long, N. J., Morse, W. C., and Newman, R. G. (1971) Conflict in the Classroom (second edition). Belmont, California: Wadsworth.
Patterson, G. R., Reid, J. B., Janes, R. R., and Conger, R. E. (1975)
Redl, F. (1959) The Concept of a 'Therapeutic Milieu'. American Journal of Orthopsychiatry 29: 721-36. Also in G. H. Weber and B. J. Haberlein (eds) (1972) Residential Treatment of Emotionally Disturbed Children. New York: Behavioral Publications.
Redl, F. (1966) When We Deal with Children. New York: Free Press.
Redl, F. and Wattenberg, M. W. (1959) Mental Hygiene in Teaching. New York: Harcourt Brace Jovanovich.
Redl, F. and Wineman, D. (1957) The Aggressive Child. New York: Free Press.
Wahler, R. G., House, A. E., and Stambaugh, E. E. (1976) Ecological Assessment of Child Problem Behavior. Elmsford, New York: Pergamon Press.