Child Adolesc Psychiatric Clin N Am

13 (2004) 255–266

Contemporary issues in the psychiatric

residential treatment of disturbed adolescents

Flynn O’Malley, PhDAdolescent Treatment Program, Outpatient Evaluation Services, The Menninger Clinic,

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine,

2801 Gessner Road, Houston, TX 77080, USA

Over the last 25 years, the practice of psychiatric residential treatment for

disturbed adolescents has undergone enormous changes. These changes in

practice have been stimulated by major alterations in financial support for such

treatment, along with administrative management, financial control, and referral

processes that bear little resemblance to those involved in the early- to mid-1980s

and before. Stimulated by the alarm of the costs of health care in general,

residential treatment is highly scrutinized by private third-party payers and public

funding sources. Managed care organizations contract to administrate health care

benefits for insurance companies and large employers and publicly funded state

agencies. The management of many large governmental users is currently

privatized. For example, Champus has for some years been organized under

Tricare, and managed care organizations bid for contracts to administrate large

regions of such governmentally supported health care plans. In the same vein,

major corporations contract with managed care firms to administrate the health

care of their employees in an effort to contain costs. Even in situations in which

benefits are managed directly by public agencies or private parties have

indemnity insurance, cost containment and case management are endemic to

the process of obtaining and maintaining funding for care.

The impact of this movement to reduce health care costs aggressively is that

lengths of stay for residential treatment of children and adolescents have been

shortened drastically, and continuity of care is difficult to maintain. These effects

fly in the face of traditional values held by individuals who provided residential

treatment in the past [1–3]. Traditional residential treatment was committed to

an emphasis on developmental growth and the nurturing structure of the thera-

peutic milieu. It emphasized the importance of reliable and sustainable relation-

1056-4993/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/S1056-4993(03)00116-0

E-mail address: fomalley@menninger.edu

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266256

ships with youngsters who may have suffered abuse or who, for other reasons,

have fundamental troubles in relatedness. It recognized the necessity of time and

patience in dealing with young people with vulnerabilities to serious mental

illness, multiple and difficult-to-treat symptoms, and troubled families.

The fear that unbridled health care costs will lead to economic disaster is

unlikely to change, and managed care has proved itself relatively successful in

containing such costs. Use of residential treatment usually requires precertifica-

tion by third-party payers and is closely monitored, and its continued necessity

is challenged as frequently as weekly or even daily. Even when the treatment

is approved, reviewers are reluctant to authorize payment for residential treat-

ment that exceeds 2 months. Some families can afford to supplement financial

support so that treatment can be extended; however, many families have no

such resources.

With the pressure to move patients to less costly levels of care, health care

providers currently face having to create new models of residential treatment

that can quickly demonstrate effectiveness on a patient’s functioning in the short

run and make a positive difference in the overall course of a youngster’s treat-

ment in the long term.

The adolescent treatment program at the Menninger Clinic

Since the mid-1980s, when lengths of stay began to shorten, the Menninger

Clinic has worked to refine its program of residential treatment for disturbed

adolescents. Clinical leadership determined that many disturbed adolescents could

benefit from an intensive program with a length of stay of 2 to 4 months. The

effectiveness of such treatment was related to patient variables [4,5] and to spe-

cific aspects of the program. In refining the program the clinic has focused on

one basic question: What essential ingredients are needed to ensure that treatment

is effective and treatment gains are sustained?

The biopsychosocial model

The clinic endorses a biopsychosocial approach to psychiatric diagnostic

understanding and treatment [6]. One aspect of the biologic view is that it

recognizes that youngsters may be vulnerable to certain kinds of disorders

because of their inherited characteristics or physical trauma or illnesses. For

example, a patient who has a family history of affective disorder or substance

abuse is not necessarily destined to have such disorders but may be more

genetically ‘‘loaded’’ to have such problems than other youngsters. A patient

with a bipolar disorder can be made aware of his or her vulnerability, begin

to take responsibility for monitoring the changes in moods, and develop plans

for minimizing the effects of the illness. This allows a person to feel less guilt

and acquire a greater sense of control over such problems. Another aspect of

the biologic view is an appreciation for the help that modern psychotropic

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266 257

medications can provide in ameliorating symptoms and allowing for greater

accessibility to treatment for many patients. Adolescent patients are capable of

learning that medications are usually not a ‘‘cure’’ but rather an aid in helping

patients manage their problems. Again, this helps patients feel more responsibility

and control.

The psychological point of view recognizes that youngsters may have had

experiences that have affected them significantly. Abuse and various kinds of

developmental failure are common. Psychodynamic therapies long have empha-

sized the role of defenses and the nature of object relations in understanding

psychiatric patients. One’s interpretation of experiences is also central to the

development of psychiatric problems and their amelioration, as exemplified by

cognitive behavior therapies. How patients view themselves, others in their

world, and life events is central to the diagnostic understanding and treatment

of virtually all psychiatric patients.

Finally, youngsters come from a familial and cultural context, which usually

contributes strengths and weaknesses and difficulties. A youngster is likely to

continue to live in, or at least be strongly influenced by, the nature of the family

and cultural system. Achieving an understanding of the family system, including

the extended family and multigenerational family patterns and events, is

important in developing a sense of the context of a patient’s problems. It also

is crucial to engage family members as participants in the diagnostic process and

create a sense of ownership and responsibility for successful outcome within each

person in the family without creating an atmosphere of guilt and blame. Our

findings consistently have supported the view that treatment outcome depends on

the establishment of a positive treatment alliance not only with the patient but

also with the family.

The diagnostic process

Achieving a comprehensive diagnostic understanding of a patient’s problems

can be time consuming and expensive. Failing to focus attention on understand-

ing a patient and the factors that contribute to the presenting problems, however,

runs the risk of treatment failure because critical issues may not be understood

and addressed.

Time is of the essence in short-term residential treatment. As such, the

diagnostic process is formalized at the beginning in determining what diagnos-

tic tools and processes are necessary to achieve a beginning understanding of

the central issues. While attempting to engage patients and family in treatment

from the outset, there also is a concentration on the diagnostic process early on.

This culminates in a diagnostic and treatment planning conference that takes

place usually within 2 weeks of admission. The treatment team reports findings

from the various diagnostic processes and reviews progress in the initial stages

of treatment. This process serves to identify the issues that seem most central

in driving a patient’s symptomatic patterns and behavior. These issues may

include the identification of dysfunctional processes within the patient or family

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266258

system, cognitive and emotional deficits that may need remediation or the

learning of compensatory mechanisms (eg, learning disabilities), and the need

for direct amelioration, such as medication, for presenting symptoms.

This initial focus on establishing clarity regarding patients and their social

system establishes a beginning for treatment focus. The diagnostic process is

an ongoing aspect of treatment, however, and new information about patients

helps to clarify and refine this understanding. Each level of refinement helps

to inform the treatment plan so that the diagnostic process and the provision of

treatment are essentially an ongoing dynamic dialog. Every member of the treat-

ment team regularly contributes to this review and refinement of diagnostic un-

derstanding and treatment planning.

The team

Concepts of the therapeutic milieu for adolescents in residential treatment

have been well discussed in the literature [7–9]. Traditionally, the best treatment

teams operated like a family, with the various members of the team taking on

benign, supportive, yet firm and consistent parenting roles. Short-term treatment

requires the establishment of a ‘‘working team.’’ Team members take on

identified roles and responsibilities for specific aspects of the treatment and the

focus on particular goals. For example, the chemical dependency counselor must

formulate and coordinate the aspects of treatment that pertain to substance abuse

and addiction. The nurses and mental health counselors are responsible for the

day-to-day functioning of the patients but are also centrally involved in the

direction of various program groups and activities that focus on patients’ central

issues. Teachers attempt to help patients return to productivity at school. Social

workers have their roles with the casework, family therapy, and discharge

planning. The team leaders provide individual psychotherapy and are responsi-

ble for maintaining an overview of the treatment. The attending psychiatrist has

medical and psychiatric responsibilities, especially in the evaluation of medica-

tion regimens.

As important as it is to identify specific roles and responsibilities, this factor

in itself can lead to isolation of the team members and fragmentation of the

treatment. The author subscribes to the view that the ‘‘holding environment’’ [10]

remains a useful and central concept in short-term residential treatment, just as

it did in longer forms of treatment. The working team is not a family, but it

should feel like one. Relatedness, interpersonal trust, and engagement form the

basis for therapeutic encounter and facilitate the willingness of the patient and

family to explore areas of their lives that are difficult for them but are crucial

to successful treatment. Each team member works to establish a trusting re-

lationship with the patient. Team discussions often focus on the contrasting

experiences that staff members have with patients and families. These differences

provide valuable information about the patients’ and families’ varying modes of

conduct and relatedness, and team discussions often reveal issues that require

attention and treatment.

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266 259

So far this discussion has focused on the program team. Especially in short-

term residential treatment, in which treatment usually begins elsewhere and will

continue with other providers, these colleagues, usually in the home community,

must be made to feel that they are part of the team from the first contacts through

treatment, aftercare planning, and discharge. Reporting progress to them periodi-

cally and seeking their insights serves to keep them involved and interested in

the patient. It also underscores their value and feeling of continued participa-

tion, which is essential to successful aftercare.

Psychotherapies and psychoeducational processes

Individual, group, and family psychotherapy processes are highly valued and

emphasized as critical aspects of the treatment program. Many patients’ func-

tioning and development are hampered by their failure to develop certain skills or

learn to cope with their limitations, however. Psychotherapy may be helpful in

these situations, but other specialized training and education can provide

additional and sometimes necessary support in dealing with these problem areas.

The specialized academic school provides an avenue for achievement in which

there has previously been failure. Patients with a history of substance abuse

require various individual and group approaches to address their addictive

behavior. Patients who are driven to inflict injuries on themselves, such as

cutting, and individuals with eating disorders also often benefit from groups that

focus on addictive patterns. Several psychoeducational groups have been devel-

oped that focus on areas such as coping with trauma [11,12], helping patients

with psychotic disorders to think more clearly through neurocognitive training

[13], and managing anger and other emotions. Dialectic behavior therapy groups

[14] are developed for patients who exhibit parasuicidal behavior and have

borderline personality traits.

Summary

Short-term residential treatment is driven and informed by a diagnostic

understanding of the central and most salient biopsychosocial elements that

contribute to and impact the functioning of the patient. Treatment is multidimen-

sional in nature, bringing to bear various complementary modes of therapy and

education. The working team strives to operate as one unified force and attempts

to engage patients and family in working toward collaboration and problem

solving. The power of positive relatedness in every aspect of a patient’s treatment

experience is critical to the development of a working relationship and the ability

of the patient to explore genuinely those issues that may be most difficult, yet

necessary to address.

The final section of this article is devoted to a single case and the patient’s

course of psychotherapy in the context of a supportive and integrated residen-

tial treatment. New ideas have emerged in recent years that help to refine and

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266260

more precisely understand the nature of relatedness and the development of cog-

nitive and emotional structures in psychotherapy.

Mentalizing

The concepts of the therapeutic alliance and collaboration in treatment have

been central to the literature on psychotherapy. The therapeutic alliance has been

examined widely as a crucial aspect in psychoanalysis and dynamically oriented

psychotherapy [15–18]. The role of the therapeutic alliance also has been stud-

ied as part of hospital and residential treatment [19,20]. These studies have shown

that the quality of the therapeutic alliance is essential to the treatment process and

sustained positive outcome.

O’Malley [21] focused on precursors to collaboration in the treatment of

hospitalized adolescents. Collaboration is defined as ‘‘both the active use of

treatment for constructive change, and the recognition of one’s own contribution

to problems and the taking of some responsibility for their resolution.’’ Precur-

sors to collaboration include a patient’s acceptance of containment, the commu-

nication of symptoms, developmental achievements (eg, academic performance),

the formation of attachments, and cooperation in solving problems related to

conflict-free areas of a patient’s functioning. Ideally, these processes lead to active

collaboration regarding the patient’s core problems. This level of collaboration

involves what Munich [6] has characterized as the patient’s acceptance of his or

her agency for the illness.

Collaborative behavior is sometimes a difficult goal to achieve with adoles-

cents in residential or hospital care, who may have been coerced into treatment,

do not trust adults, and rebel against their care providers as a way to hold on

to some semblance of autonomy. This latter problem is well articulated by

Blos [22].

Recently, the literature on child development and psychotherapy has begun

to incorporate a more modern term: mentalizing. According to Allen and

Fonagy [23], mentalizing is a capacity. Although it is related to such concepts

as psychological mindedness, observing ego, empathy, and insight, it also

involves additional properties that are central and essential to the mental activ-

ity of psychotherapist and patient. Allen [24] describes mentalizing as treating

others as persons rather than objects. Mentalizing involves the ability to think

about another person, to formulate ideas about his or her mental life and

empathize with and mirror back to the other person a sense of emotional

attunement. Mentalizing also includes the ability to entertain multiple perspec-

tives about other people, their points of view, and the nature of one’s own life

experiences. Most importantly, the capacity to mentalize reflects the evolution

of healthy and secure emotional attachments and is compromised by insecure

attachments produced by maltreatment and emotional trauma. Many disturbed

adolescent patients have great difficulty mentalizing. This capacity, which is

essential for positive treatment and personal development, is facilitated by

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266 261

the actions of the therapist in psychotherapy and by the entire team in hospital

and residential treatment.

Case study

The following case was chosen to illustrate the some of the aspects of

mentalizing and their importance in the process of a difficult psychotherapy.

The case may be of specific interest because of the developmental arrest that

incapacitated the patient and left him isolated and his distrust and dismissive

attitude about the possibility of being helped and understood by adults in

authority. The patient’s initial unwillingness to allow care providers into his

world, his determination to see himself as unable to move into adulthood, and his

pessimism about life in general were countered by certain positive attributes

and experiences along with some healthy early developmental attachments. Cer-

tain aspects of the patient’s background, family situation, and therapeutic events

have been altered to protect his anonymity; however, the elements believed to be

essential to an understanding of the process remain.

I saw Charles in twice-weekly individual psychotherapy sessions for approxi-

mately 4 months in the context of intensive residential psychiatric treatment. At

age 17, he was the younger of two children of an affluent professional couple.

The father was a prominent attorney who was highly successful, and the mother

was a specialist in the area of learning disabilities. The patient’s older sister was

academically gifted and socially successful. The father often was away from

home on business. Charles, on the other hand, was socially awkward, had

learning disabilities in the area of written expression, and was disinterested and

poor in sports. His father had hoped for a son who could be a champion in sports

and an academic and social star. The father tried to contain his disappointment,

but his sensitive son felt the father’s disapproval from an early age. To make

matters worse, the boy was teased at school, and his vulnerability to the contempt

of his peers grew as the teasing intensified in middle school and high school. In

his senior year, he felt so tormented that he refused to go to school and retreated

to his room and his computer. Attempts were made to engage him in outpatient

therapy, but he was uncommunicative in these processes and refused to attend the

sessions. He continued to take his medications for attention-deficit hyperactivity

disorder but refused medications for depression. At the time of his admission, he

was taking his meals in his room alone and avoiding his father. He allowed his

mother to look after his needs but rejected all her suggestions and attempts to

encourage him to become more involved in the world. Charles was admitted to

the adolescent program at the Menninger Clinic when his parents discovered

notes he had written that suggested suicidal ideation.

Upon admission, Charles made little eye contact. His affect was flat, but

there were occasional flashes of anger in response to his parents’ descriptions

of him and his problems. He denied having any problems except the harass-

ment and demands of his parents. He did, however, acknowledge that he

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266262

had been truly traumatized by his peers at school and that his only social

contacts were people he met on the computer while playing interactive com-

puter games.

On the residential unit, Charles kept to his room whenever possible, but he did

go to meetings and groups, although he initially remained silent. He engaged little

with the other patients who tried to include him in their activities. He repeatedly

reported to unit staff members that there was no purpose to be served by his

treatment, he was happy being alone at home, and he had submitted to treatment

only to get his parents to leave him alone. He also acknowledged that it was of

some relief to be away from them.

Charles was not allowed to have his computer in the treatment setting, so the

prospect of retreating to his room was less inviting than it had been at home. He

willingly went to the program’s school on campus, especially after he felt

reassured that his fellow students would not tease him in some cruel fashion.

He balked at doing written assignments for fear that his disabilities would

become easily apparent. He was a voracious reader despite his problems with

writing. After a time he began to participate in discussions in his classes,

especially when the discussions were of interest to him.

Charles was compliant in coming to his psychotherapy sessions with me, but

he was quick to point out that they would do no good and were a waste of time

for both of us. I acknowledged that he had experienced his previous psychother-

apy as unproductive to him, and I encouraged him to be patient with me, as I

would be patient with him, and that we would try to do the best we could. The

feeling that I would not make demands on him that he could not meet and the

idea that we were both not perfect seemed to appeal to him somewhat. This

was evidence to me of some potential to ‘‘meet me half-way,’’ especially if he

believed that I would not lay into him with criticism about how he had managed

his difficulties.

In the subsequent sessions I did not at first address his problems but rather

inquired about his interests. I asked about his fascination with computers and

the interactive games he played with others. The other players, living in other

parts of the country, had become his social network. He was angry that he had

been cut off from them. I acknowledged that he seemed to have people he felt

comfortable with and, in fact, missed their activities together. I addressed his

other interests, including his reading preferences, and discovered that he was a

science fiction fan. We discussed various types of the genre, and he revealed

himself to be well versed in this literature. By chance, I had read enough of the

older science fiction literature to converse with him about it. These were in-

teresting discussions, but he eventually pointed out that they had little to do with

his presenting problems. I agreed with that and openly acknowledged that I was

trying to establish common ground for us to talk about other things as well. He

asked for an update on my view of his problems. I told him that I believed he had

been truly traumatized by his school experiences but that as a practical matter,

sooner or later his parents would likely insist that he become more independent

and not remain totally at home. He replied that he knew this was coming but

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266 263

currently had chosen to ignore the eventual problem. I suggested that perhaps

understanding what he had been through and what he currently feared might help

us devise a plan for his gradual resocialization. He admitted that the prospect of

going out in his home community was frightening to him. He was afraid he

would see people he knew and would have to suffer shame and humiliation from

their comments or nonverbal expressions toward him. This opened the door for

review of his earlier trauma. I believe that Charles’ willingness to talk more

candidly with me was aided by my expressed view that my purpose was to help

him but also that I saw his situation as less reflective of deficits and faults in him

than as a practical matter that needed attention.

Charles continued to deny any real problems at home that were not caused

by his parents’ demanding nature, and he disparaged any hope of improving

his relationship with them. He acknowledged that his mother cared about him

but held contempt for what he considered her nagging; he expressed feelings

of hatred for his father. He was able to describe occasions when his father had

berated and humiliated him. He was, however, feeling more comfortable with

his peers in treatment with him, but he maintained that this was situation-spe-

cific and that his anxiety about having contact with peers at his home school

and community was crippling. I felt that this period of treatment reflected his

growing confidence that he could reveal his poignant fears of humiliation with-

out suffering humiliation in doing so. I thought this development reflected

his feeling that I ‘‘had his mind in mind’’ and that I would not shame him.

Charles began to share experiences about his relations on the hospital unit. He

reported offering ideas and advice to his fellow patients and implied that they had

some appreciation for his intelligence and wry humor. I asked about other

experiences in which he had felt appreciated. He recalled working for a time

as a volunteer at a preschool. He was surprised when he received a great deal of

positive feedback from the preschool teacher at the conclusion of the job. Mostly,

he was touched by the outcry of the children who said they would miss him. He

continued to feel some guilt at having left them. We talked about how he must

have been gentle, friendly, and empathic with them for them to miss him so

much. He said he did feel that he understood them but had no idea that he had any

significant impact on them. Charles was so sensitive to slights and inauthentic

encouragement that I do not believe he would have been able to take in my

comments if he had felt they were not genuine. In a sense, Charles had begun to

have ‘‘my mind in mind.’’

Charles began to plan for his aftercare. We discussed ways in which he might

move forward and allow more social experience. He could not tolerate the idea of

returning to his school, and he negotiated with his parents to take the GED. He

did think he might be able to attend a class at the local community college and

perhaps get a job. He went on a home pass, which went well. He was able to be

cordial to his father and somewhat affectionate with his mother. He noted that his

father seemed to be trying to be friendlier, but Charles’ resentment ran too deep to

allow any closeness with him. With other adults, Charles seemed to be coming

out of his shell on the basis that he had developed a greater ability to expect

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266264

respect and acceptance. His relations with peers on the unit continued to improve,

and they began to express regret at his expected leaving.

Charles went off grounds to take a pre-GED examination. Upon return he

reported to staff members on the unit and then to me that he had had an

‘‘epiphany’’ while taking the test. In the middle of answering an essay question

(not easy for him), he had the experience that he had concentrated so much on the

cruel and disappointing things that had happened to him that he had overlooked

the good things. He remembered some good times that he had in the past. He

acknowledged that his parents, although they made mistakes, almost always had

his interests at heart. He even felt his father was ‘‘just human,’’ basically another

father who wanted his son to be successful and independent. The patient

discussed this ‘‘epiphany’’ with his parents, and it continued to dominate his

feelings about his treatment until his discharge. I believe this experience of the

patient reflected his own growth in being able to ‘‘mentalize,’’ to see other people

as people rather than objects and the sources of his unhappiness.

Charles was discharged home to begin his aftercare plan. Contact some

months later revealed that he had continued to do well but that he had a period

of depression when he felt rejected by a girl who had been a former patient

and knew him on the unit. He recovered from this, however, and moved forward.

Charles had taken a chance on a romantic relationship, something that would

have been unthinkable before his treatment. He had allowed himself to be hurt

and found that he could recover.

As a psychotherapist, the idea of mentalizing was helpful in thinking about

this case. Mentalizing can be thought of as flowing along two parallel tracks.

One track involves the mental activities and interventions of the therapist. The

other track can be seen as the evolution of mentalizing in the patient. Allen [24]

points out that therapists and other team members cannot facilitate mentalizing

in the patient without engaging in mentalizing ourselves. Some of this includes

‘‘thinking about’’ patients, trying to establish a sense of ‘‘working together’’

toward some common goals, providing empathy, and offering alternatives to

rigid or personalized thinking without criticizing or shaming patients. The efforts

of the team members who work day-to-day on the unit includes providing

structure and a secure, reliable environment, but it also involves ‘‘having a

patient’s mind in mind’’ and communicating that to patients. This process is

also part of working with the family. While offering guidance and sometimes

confronting dysfunctional or damaging behavior, the social worker or other

professional communicates an appreciation for the experiences and troubles of

the parents, which allows them to open doors for deeper, more authentic work

in the family therapy process.

In summary, the concept of mentalizing seems to capture much of the intricate

mental work of the therapist and other team members who attempt to establish a

trusting relationship with patients. It is hard work to be in two places at once—

to be observing the activities and listening to the communications of a patient

while simultaneously attempting to connect with a patient’s true nature and ex-

periences by having his or her ‘‘mind in mind.’’ Finally, it is through the com-

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266 265

munication of this process by the actions and words of the therapist that patients

begin to alter and expand their views and perspectives and ultimately undergo

the ‘‘corrective emotional experience’’ described long ago by Alexander and

French [25].

Summary

This article reviewed the current challenges to the provision of residential

treatment for disturbed adolescents, described the Menninger Clinic’s model

for short-term residential treatment that has been developed over the last 10 years

to meet these challenges, and provided a case example to exemplify the role of

such newly developed concepts as ‘‘mentalizing’’ in the provision of psychi-

atric treatment.

Stimulated by the alarm of the costs of health care in general, residential

treatment is highly scrutinized by private third-party payers and public funding

sources. The impact of this movement to reduce health care costs aggressively is

that lengths of stay for residential treatment of children and adolescents have been

shortened and continuity of care is difficult to maintain. Since the mid-1980s,

when lengths of stay began to shorten, the Menninger Clinic has worked to

develop an intensive program with a length of stay of 2 to 4 months. The essential

ingredients needed to ensure that treatment is effective and that treatment gains

are sustained were described. Finally, a case was used to illustrate current views

of understanding some of the processes that engage patients and stimulate

changes in several variables.

References

[1] Bettleheim B. Love is not enough. Glencoe (IL): Free Press; 1950.

[2] Masterson J. Treatment of the borderline adolescent: a developmental approach. New York:

Wiley-Interscience; 1972.

[3] Rinsley D. Treatment of the disturbed adolescent. New York: Aronson; 1980.

[4] O’Malley F. Short-term residential treatment of disturbed adolescents in a continuum of care.

Child Youth Serv Rev 1993;15(3):245–60.

[5] O’Malley F. Critical issues in short-term residential treatment. Residential Treatment for Chil-

dren and Youth 1996;14(1):61–74.

[6] Munich R. Efforts to preserve the mind in contemporary hospital treatment. Presented at the

symposium on the relation of attachment disorders to clinical practice. January 2002, Houston.

[7] Redl F. The concept of the therapeutic milieu. Am J Orthopsychiatry 1950;29:721–36.

[8] Trieschman A, Whittaker J, Brendtro L. The other 23 hours: child-care work with emotionally

disturbed children in a therapeutic milieu. New York: Aldine de Gruyter; 1969.

[9] Viner J. Milieu concepts for short-term hospital treatment of borderline patients. Psychiatr Q

1985;57:127–33.

[10] Winnicott D. The maturational processes and facilitating environment. New York: International

Universities Press; 1965.

[11] Allen J. Coping with trauma: a guide to self understanding. Washington, DC: American Psychi-

atric Press; 1995.

F. O’Malley / Child Adolesc Psychiatric Clin N Am 13 (2004) 255–266266

[12] Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols and

procedures. New York: Guilford Press; 1995.

[13] Brenner H, Roder V, Hodel B, Kienzle N, Liberman R. Integrative psychological therapy for

schizophrenic patients. Toronto: Hogrefe & Huber Publishers; 1994.

[14] Linehan M. Cognitive-behavioral treatment of borderline personality disorders. New York:

Guilford Press; 1993.

[15] Frieswyk S, Colson D, Allen J. Conceptualizing the therapeutic alliance from a psychoanalytic

perspective. Psychotherapy 1984;21:460–4.

[16] Greenson R. The technique and practice of psychoanalysis. New York: International Universities

Press; 1967.

[17] Horwitz L. Clinical prediction in psychotherapy. New York: Aronson; 1974.

[18] Luborsky L. Helping alliances in psychotherapy. In: Claghorn J, editor. Successful psycho-

therapy. New York: Brunner/Mazel; 1976. p. 92–116.

[19] Allen J, Deering C, Buskirk J, Coyne L. Assessment of therapeutic alliances in the psychiatric

hospital milieu. Psychiatry 1988;51:291–9.

[20] Allen J, Tarnoff G, Coyne L. Therapeutic alliance and long-term hospital treatment outcome.

Compr Psychiatry 1985;26:187–94.

[21] O’Malley F. Developing a therapeutic alliance in the hospital treatment of disturbed adoles-

cents. In: Menninger W, Allen J, Leichtman M, Myers J, editors. Hospitalization in the psychi-

atric treatment of children and adolescents. Topeka: The Menninger Foundation; 1990. p. 13–24.

[22] Blos P. The second individuation process of adolescence. Psychoanal Study Child 1967;22:

162–86.

[23] Allen JG, Fonagy P. The development of mentalizing and its role in psychopathology and

psychotherapy (technical report No. 02–0048). Topeka: The Menninger Clinic; 2002.

[24] Allen JG. Mentalizing. Bull Menninger Clin 2003;67:91–112.

[25] Alexander F, French S. Psychoanalytic therapy. New York: Ronald Press; 1946.