Psychotherapy in Group Care

Making Life Good Enough

D Patrick Zimmerman, Richard A. Epstein Jr, Martin Leichtman, Maria Leichtman

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781317787181
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Integrate psychotherapy with residential treatment to achieve positive results for patients in group care!

This book addresses the complex issues that arise in the effort to provide individual therapy in group care settings. It reviews classical case material, presents contemporary case studies, and examines practical and theoretical issues important to the effective delivery of treatment to individuals living in residential care.

Noted experts who have been associated with The Sonia Shankman Orthogenic School at the University of Chicago and the Menninger Clinic in Topeka, Kansas, share knowledge garnered from years of real-world experience to help you stay at the leading edge of the field and provide effective individual treatment to your clients in long- and short-term residential care.

Psychotherapy in Group Care: Making Life Good Enough includes practical and theoretical chapters exploring important aspects of the group care paradigm. The book:

• presents a case study that describes vital aspects of the analytic process that emerged in work with an adolescent boy in a group home who felt as though he was a psychological orphan
• illustrates the role of play as a continuous and basic function in therapy and presents play-themed vignettes from analytic work with two young people in residential care
• revisits Joey: A Mechanical Boy and Tommy the Space Childclassic case studies from Bruno Bettelheim and Rudolph Ekstienand explores the implications of contemporary relational theory for using the meaning and metaphor of behaviors and communications
• addresses issues of transference and counter-transference in the psychodynamic psychotherapy of a young girl in residential carewith a discussion of unrecognized rescue fantasies and projective identification, and of the need for residential childcare workers to recognize and work through the difficult feelings evoked in the process of working with seriously disturbed young people
• examines the structural basis for the integration of psychotherapy and residential treatment, considering the meaning of integration, variables that affect the manner and degree to which integration can be accomplished, and changes in the psychotherapists' roles that can maximize the potential of each variable
• explores three sets of theoretical issues facing clinicians as they play multiple roles in short-term residential treatment, discussing how conflicts in the roles of therapists and team leaders can be resolved, the implications of such a resolution in terms of confidentiality, and ways in which major approaches to psychotherapy can be adapted to new conditions
• considers the role of the primary clinician in relation to the residential team and explores the ways in which integration of psychotherapy and residential treatment can be implemented in the early phase of the treatment process

The Integration of Psychotherapy and Residential Treatment in an Intensive Short-Term Treatment Program: Part I. Structural Considerations

Martin Leichtman, PhD

Maria Luisa Leichtman, PhD

Summary. This paper examines the structural basis for the integration of psychotherapy and residential treatment by considering: (1) what is meant by integration; (2) variables bearing on the manner and degree to which it can be accomplished; and (3) changes in the roles of psychotherapists that maximize each of those variables. Subsequent papers will consider ways in which approaches to psychotherapy can be adapted to the altered forms of clinical practice these changes entail and specific ways in which that integration was accomplished in each phase of the treatment process. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2003 by The Haworth Press, Inc. All rights reserved.]

Keywords. Short-term residential treatment, therapist-resident interactions, psychotherapy and residential treatment, integration of treatment processes, psychotherapy process

In recent papers, we described a model of intensive short-term residential treatment for severely disturbed adolescents and follow-up data on its effectiveness (Leichtman & Leichtman, 1996a, 1996b, 1996c; Leichtman, Leichtman, Barber, & Neese, 2001). The term “intensive” was used to denote that the model was developed to provide services comparable to those of intermediate- and long-term psychiatric hospitals that were no longer readily available after the managed care revolution of the early 1990s. That is to say, the program (1) was intended for adolescents with psychoses, serious character pathology, and marked anxiety and affective disorders whose self-injurious acting-out, incapacitating symptoms, and failure to negotiate social and adaptational tasks could not be managed through comprehensive outpatient treatment and/or brief hospitalizations, and (2) included the same basic services (e.g., a structured, carefully supervised milieu, medication, psychotherapy, group therapy, family therapy, and specialized treatments for substance abuse, eating problems, and trauma) formerly offered in those hospitals.

The model was “residential” in the sense that it was organized around principles that distinguish that modality from other forms of inpatient treatment. It was based on the assumptions that: (1) to address severe psychopathology, it is essential to help children negotiate basic tasks of daily living effectively; (2) such treatment requires a coordinated team, each of whose members work on common therapeutic issues in their own ways; (3) the central agents of change are the caretakers, the childcare staff, who are most directly involved in this process; and (4) all other aspects of treatment must be organized around and fed into the work of the residential unit. The model was “short-term” not only in the sense that typical lengths of stay were 3 to 4 months, far less than those characteristic of traditional residential programs, but also that treatment was based on principles common to short-term therapies of all kinds (Budman & Gurman, 1988; Leichtman & Leichtman, 1996b).

An essential feature of this program was the rigorous integration of psychotherapy with other aspects of residential treatment, especially the work of the childcare staff. This paper examines the structural basis for this process by considering: (1) what is meant by integration; (2) variables bearing on the manner and degree to which it can be accomplished; and (3) changes in the roles of psychotherapists that maximize each of those variables. Subsequent papers will consider ways in which approaches to psychotherapy can be adapted to the altered forms of clinical practice these changes entail and specific ways in which that integration was accomplished in each phase of the treatment process.

Therapist-Residence Interactions

What is described as the integration of the psychotherapy and residential treatment may involve a wide range of interactions between team members. A good point of departure for understanding them is a consideration of what therapists and unit staff may seek from one another.

Therapists usually wish three types of assistance from childcare workers that are similar to those from parents in outpatient psychotherapy processes. First, they are dependent on the residential unit, as they are on parents, for such basic support as getting children to therapy on time, conveying a sense of its importance, and dealing with children’s resistance to the process during difficult periods when they may not make use of therapy or even balk at coming to it. Second, therapists typically would like caretakers to provide information about children’s behavior, the circumstances of their day-to-day lives, and environmental factors impinging on them. Such information may help determine problems to be worked on in therapy, establish a context for understanding material arising in sessions, and serve as a means of assessing whether children are improving or not. Third, as therapists learn about factors in children’s lives that contribute to problems or inhibit their growth, they may wish parents or caretakers to make changes in the environment or alter patterns of interaction within the family. At times, therapists go farther and use caretakers as their surrogates in such tasks as helping children face anxiety-arousing situations or providing coaching and assistance in controlling aggression or improving relationships with siblings or peers.

What unit staff need from therapists may be understood in terms of two basic assumptions about what is curative in residential treatment. One, implicit in the concepts of the therapeutic milieu and “the other 23 hours” (Trieschman, Whittaker, & Brendtro, 1969), is that whatever is done to enable troubled children to negotiate basic tasks of daily living (waking, grooming, eating, school, recreation, relations with caretakers and peers, etc.) is in innumerable small, but cumulatively large, ways treating the anxiety, depression, aggression, thought disorder, or other types of psychopathology that have disrupted their lives and that, even if such interventions cannot eliminate symptoms entirely, they can provide children with the adaptive skills to live satisfying lives in spite of their problems. Childcare staff, who are chiefly responsible for this aspect of treatment, often wish that therapists would assist them by making these issues a major focus of the psychotherapy process as well and by providing extensive consultation to help them deal with pathology that interferes with children managing these tasks.

The other assumption that distinguishes residential treatment as a modality, that embodied in the concept of the “life space interview” (Redl, 1966), is that symptoms are best addressed while they are occurring or shortly afterward. If therapy could be conducted at these times, the events leading to problems and their sequence would be fresh in everyone’s minds and have affective resonance as they may not in the next formal psychotherapy session several days later; children’s defenses are down; and therapists can apply “emotional first aid” to prevent symptoms from mushrooming into full-fledged crises. Such interviews often cannot be conducted by psychotherapists, who cannot be on residential units 24 hours a day, but they are possible if the staff who are with children at these times perform these functions as well. Hence, in so far as they conduct such “life space interviews,” childcare workers may wish therapists to accept the sharing of the psychotherapy role, supply information about children’s conflicts and dynamics to enable workers to conduct such interviews better, and offer guidance and even supervision in doing so.

Variables Bearing on the Integration of Psychotherapy and Residential Programs

Because the integration of psychotherapy and residential treatment may involve a variety of interactions between therapists and the residential unit, the manner and extent to which it takes place in any given program varies considerably. Moreover, because therapists and unit staff within the same program have their own distinct perspectives and priorities, each may prefer types of interactions, and the very meaning of “integration” may differ for each. Consequently, how and to what degree psychotherapy and residential treatment are integrated is determined by a number of variables.

One is the treatment philosophies that govern each process. As a rule, therapists prefer to work with residential staff in the same ways they do with parents in outpatient processes. For example, some psychotherapists (e.g., Axline, 1969; Glenn, 1978; Weiss, 1964) focus chiefly on events within the session itself and limit communication with caretakers. Others, such as many psychoanalytically-oriented therapists, may seek information about children’s lives and provide feedback to caretakers, but do so in controlled, delimited ways intended to preserve confidentiality and maintain the boundaries of the therapy relationship (e.g., Coppolillo, 1987). Still other therapists welcome as much sharing of information and consultation as possible. The degree of integration may also vary with the cases treated. As a rule, therapists favor more extensive and more candid interchanges around younger and more disturbed clients than around older and more intact ones. Similarly, residential programs differ in how much and what kind of input they seek from therapists. Typically, they are likely to want more extensive information and consultation than therapists. However, some may be most comfortable with keeping the two types of treatment processes separate because of set residential treatment protocols, concerns that too much consultation from therapists can confuse and disrupt treatment on the units (especially if there are several therapists with different orientations), or practical considerations such as cost and logistics.

A closely related factor is the treatment philosophy that governs the residential system as a whole. Systems differ in the degree to which integration is valued (Monahan, 1989). As noted, some are content with both processes being discrete or with limited interchange either for theoretical reasons (e.g., concerns about preserving the integrity of each treatment process) or because of the time, expense, and energy involved in doing otherwise. Others expect extensive contact between therapists and the residence. The overriding philosophies also determine who sets the terms of integration when there are differences between the residence and therapists. For example, in a number of early programs, psychoanalysis and psychotherapy were viewed as the preeminent component of treatment. The residence was to provide a benign living environment while the primary therapeutic work occurred in an intensive psychotherapy process. Therapists thus might receive more information from the residential team than they returned and could expect their recommendations regarding children’s needs on the unit to be put into practice. In contrast, over the years, work on the residence assumed increasing importance and in many programs psychotherapy came to be considered only one of a number of concurrent treatments. In such programs, there might be tolerance for treating each process as separate or therapists might be expected to integrate their work on the residence’s terms, with referrals and even employment being contingent upon their willingness to accept those terms.

Another variable is the status of psychotherapists in the residential system. In programs in which psychotherapy was conducted by psychoanalysts or other experienced, highly-trained clinicians, therapists could expect their requests for information to be taken seriously and for their recommendations to have a significant impact on the residential treatment process. In contrast, in programs in which psychotherapy is conducted by less sophisticated clinicians with relatively modest credentials, the views of therapists carry less weight with the residential team. All other things being equal, the greater the power and authority of the psychotherapist, the greater the degree to which the psychotherapy process may influence residential treatment.

All other things are seldom equal, however. For example, even if the word of a psychoanalyst consulting to a residential team is accorded the authority of the Holy Writ, ordinary mortals on the unit might be limited in their understanding of the therapist’s intent or even take a sinful pleasure in ignoring it, especially if the therapist is viewed as an outsider. Therapy is more likely to be coordinated with the work of the rest of the residential program when therapists are viewed as integral parts of the residential team than when they are seen as peripheral or not part of the team at all.

Finally, even when the administration, therapist, and unit staff wish for a high degree of integration of treatment processes, the extent to which it actually occurs depends on communication within the team. Such communication may be affected by geography (e.g., whether therapists’ offices are on or near the unit or whether they are off the service or even outside the institution), the frequency of meetings and their agendas, and time demands on staff (e.g., whether there are opportunities for informal exchange of information). Obviously, programs with regular meetings attended by therapists, ones in which therapists are on the unit often, and ones in which staff can exchange information frequently in both formal and informal ways are more likely to coordinate the two types of treatment processes than ones in which there is limited and infrequent contact.

The Role of the Primary Clinician and the Integration of Treatment Processes

Assuming that a high degree of synthesis is necessary in order to handle diminished lengths of stay and make comprehensive treatment economical, intensive, short-term residential treatment places a premium on the integration of psychotherapy and all other aspects of treatment. The critical step in translating that philosophy into practice lay in a fundamental structural change in the role and functions of psychotherapists on the unit.

That change consisted of the adoption of a variation of the combined therapist-administrator model (Monahan, 1989). A single individual, a “primary clinician,” was given responsibility for providing diagnosis, treatment planning, team leadership, psychotherapy, and group therapy for a number of adolescents on the unit (Leichtman & Leichtman, 1996c). In effect, the roles of team leader, psychotherapist, and group therapist for children were combined.

The significance of this redefinition of roles lies in the fact that it maximizes each of the variables contributing to the integration of psychotherapy and residential treatment. The treatment philosophy permeating the residential program obviously makes such integration a central value. Psychotherapists, by virtue of also directing the residential program for a child, have a high status in the system and authority for decision-making. Far from being “outsiders,” primary clinicians occupy a central role in the residential team. And, since they are present at most key meetings and have numerous formal and informal contacts with staff on the residential unit daily, they are in constant communication with other members of the team and can have input into decisions about even relatively minor aspects of treatment.

In sum, the primary clinician model is one in which the potential for bringing issues on the unit into the psychotherapy process and for translating insights from the psychotherapy process into unit treatment co...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword: Psychotherapy and the Milieu: Issues Posed for Confidentiality and for the Therapist’s Participation in the Therapeutic Environment
• Preface: Child and Milieu: Tensions Between Group and Individual Care
• Is Life Good Enough? A Close Race to Make It Better
• Parallel Dimensions in Child, Adolescent, and Adult Analytic Work
• Reconsidering Classic Case Studies: The “Mechanical Boy” and the “Space Child”
• Alice’s Loss of Wonderland
• The Integration of Psychotherapy and Residential Treatment in an Intensive Short-Term Treatment Program: Part I. Structural Considerations
• The Integration of Psychotherapy and Residential Treatment in an Intensive Short-Term Treatment Program: Part II. Theoretical Considerations
• The Integration of Psychotherapy and Residential Treatment in an Intensive Short-Term Treatment Program: Part III. Implementation as Therapy Begins
• Index