A developmental approach to diagnosis and treatment in a

transitional living program

Scott Dowling, MDa

aAssociate Clinical Professor of Child Psychiatry, Case Western

Reserve University, Cleveland, Ohio.

aCorresponding author forproof and reprints:

Scott Dowling, MD

22300 S. Woodland Road

Shaker Heights, Ohio 44122

(216) 751-9711 (phone)

(216) 751-9711 (fax)

asdowling@msn.com (email)

1

Residential Treatment (RT) is the most comprehensive

interpersonal treatment modality available for children and

adolescents, providing its members 24 hours a day of integrated

milieu therapy, education and psychotherapy in a total living

environment. Transitional Living (TL), an outgrowth of RT, is

only now being conceptualized as a unique therapeutic

intervention. Although many RT programs emphasize family

participation and retain contact with the environment of the

broader community, the strength of RT lies in its autonomy as a

therapeutic community. TL combines many of the elements of RT

with guided, progressive engagement with the broader community.

It is designed for young men and women from 17 to 19 years-old,

late adolescents who must soon enter the world of higher

education or work but who lack the psychological, educational and

vocational capacities to enter that world with any reasonable

chance of success.

INTRODUCTION

This article, a discussion of a successful treatment

approach to Transitional Living, is not intended to be a survey

2

of available programs or a summation of the state of the art.

The presentation is based on my experience as medical director of

a Residential Treatment Center (RTC) for eight years (1969-77)

and, more recently, as consulting psychiatrist for a Transitional

Living Program (TLP) for 5 years (1998-2003). Morris Mayer,

Ph.D., Director of Bellefaire RTC in Cleveland, Ohio, was my

original mentor during the 1970's [1, 2, 3, 4]; he introduced me

to the seminal works of Fritz Redl [5, 6] and Bruno Bettelheim

[7] as well as to his own humanistic, optimistic and highly

energetic techniques. Ms. Eleanor Fiedler, Judy Mishne, Ph.D.,

and others, together with my training and experience in clinical

psychoanalysis, shaped my thinking as I struggled with the

problems of program development and treatment for a campus

population of 100 children in RT. Twenty-five years later, at

the invitation of Ivy Boyle, M.D., I returned to the field as

consulting psychiatrist for a TLP, also at Bellefaire 1. The

discussion will center on functional diagnosis and treatment

planning, emphasizing the importance of broadly conceived

1 A previous paper [8] describes the overall organization of the Bellefaire Transitional Living Program. Further details of the program are available fromthe author.

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developmental assessment for treatment planning and execution. My

intent is that this description and formulation, based on the

psychosocial framework of Erik Erikson [9, 10], will serve as a

point of further discussion and elaboration by others.

OBSERVATIONS ABOUT RESIDENTIAL TREATMENT

We will begin this presentation of TL with some observations

concerning RT, from which it is derived. It is one of the

puzzles of my professional life that the potential of RT is

recognized by so few and its promise so rarely realized. RT has

been a profession in which charismatic and immensely energetic

leaders have dominated the field. August Aichhorn [11], Fritz

Redl, Rudolph Ekstein [12] and Bruno Bettelheim were the

originators and are the best known of this group. A cadre of

lesser giants, devoted, hard working and consistent, Morris

Mayer, Albert Trieschman [13], Jerome Goldsmith, Joseph

Noshpitz, Rocco Motto [14], and Jacqueline Sanders, among others,

helped shape the American version of the field; still others,

attuned to community realities, are the leaders of today. The

American Association of Residential Treatment Centers, and its

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journal, Residential Treatment for Children and Youth, has been the meeting

ground of these specialists.

Altruism, therapeutic zeal and self-sacrifice fueled the

originators of RT. The image of the therapeutic community,

tinged with socialist idealism, repairing personalities injured

by hate and abuse, was utmost in their minds. Today, other goals

and intentions, often profit motivated and politically savvy,

muddy the field. For-profit hospitals provide short term,

residential treatment on hospital wards via behavior therapy and

medications or, most egregiously, in isolated punitive

circumstances, sometimes outside US legal restraints [15]. Many

programs pay lip service to the need to help youth experience

meaningful relationships and interiorize positive values but do

not provide the consistent personal relationships that these

goals require. Another approach is therapy via adventure

expeditions, dude ranches and other isolated but fun experiences.

The problem with many of these programs is not with having fun,

an essential part of any RTP or TLP, but with the assumption that

activity, distraction and imposed limits will resolve the effects

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of abuse, externalizing defenses, and undeveloped or maladaptive

values.

The largest group of available residential programs is in

undermanned state facilities, combining punitive with therapeutic

objectives. These are often isolated and highly restricted

settings with little programming for life, that is, for

autonomous functioning in an environment in which respect is both

provided and expected by others. The graduates of these programs

achieve a surface compliance and orderliness but often continue

to seethe with inner rage, living in a constricted world, defined

by the narrowness of their psychological horizons. Others suffer

from institutionalization, dependent on the care taking of staff

members, incapable of self-directed initiative and responsible

choice.

RT has been equated in the minds of many, including mental

health professionals, with these short-term private hospitals,

commercial ventures of doubtful value and inadequate state

facilities. Often, the result of these programs is young persons

who can follow rules but have no developed sense of autonomy

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linked with socially adaptive values and a capacity for action;

they lack the psychological foundation for becoming a

contributing member of a democratic society.

TRANSITIONAL LIVING PROGRAMS

It is for older youth, ages 17-19 years-old, with disordered

development linked to a combination of mental health issues (most

commonly post traumatic stress, psychosis, chronic anxiety and

depressive states, oppositional and conduct disorders),

institutionalization, delinquency and disrupted or destructive

family relationships that TLPs provide a link to effective

adulthood. Many come to TLPs from RTPs, others from group or

foster homes, psychiatric hospitals and detention facilities as

well as from the community.

TL differs philosophically and structurally from RT in one

very important respect. RT provides a full service residential

milieu, usually for school age to mid-adolescent children. TL

has one foot solidly planted in a full service residential

milieu, the other solidly planted in the broader urban community

in which it is located. The link between the two aspects of TL

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is our supportive, therapeutic participation with the youth as

they knock on the door, then enter the social, educational and

vocational life of the community. TL seeks to identify and

counteract the dependence of institutionalization or the excesses

of defensive bravado and acting out by requiring and monitoring

engagement with the vagaries of community life. TL cannot and

does not inflict any form of physical punishment or utilize

restraint or seclusion.

With both internal and external pressure to perform in the

wider community, the boy’s or girl’s conflicts and capacity (or

lack of capacity) for independent action, for family involvement,

for further education and for gainful employment quickly become

apparent. Limitations in these areas are often strongly defended

against by denial, denial in fantasy, sexual or aggressive

actions or by withdrawal, phobias, inaction and depression. The

young person may, for example, loudly state that they can get

along just fine, just leave me alone. They are given the

opportunity to demonstrate, in carefully graded steps, that they

can navigate the larger community, purchase and prepare meals,

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attend public school, fill out applications for work, deal with

the requirements of work, handle money and plan expenses. Under

these circumstances, their defenses against helplessness and

confusion become less adaptive, providing many opportunities to

discuss their habitual ways of avoiding feelings of inadequacy

and to develop new and more effective techniques of learning,

relating and acting. When the difficulties in these areas are

addressed, the underlying limits and conflicts, usually related

to family experience, become glaringly evident; appropriate

interventions can be planned and provided.

A tri-partite integrated program of milieu therapy,

education, and psychotherapy is essential to both RT and TL. But

this statement allows for broad latitude in the organization of

each of the three components in different programs. For example,

behavioral techniques will be employed in all programs but the

extent to which they are employed will vary widely. Similarly,

different methods of psychotherapy can be and are used, depending

on the interests and the training of the therapists. However,

the flexibility which provides room for innovation and creative

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programming should not extend to simply labeling a set of

cottages with supervising adults milieu therapy,or referral to

behavior disorderedclassrooms in public schools as educational

therapy, or intermittent counseling by untrained, unsupervised

workers as psychotherapy.

Each component includes a professional, in-house program,

emphasizing the primacy of respectful relationships between staff

and members and between staff and staff. Each of the three

components, as well as the organization of the components, is

important in describing a given RTP or TLP. TL utilizes these

programs to support and provide for graded experiences and

increasing autonomy by the youth within the broader community,

moving from socialization in the cottage to planned activities in

the community; from a campus school with special education

facilities to public school, GED preparation, vocational training

or college; from self management in the cottage to competence in

an outside work experience.

THE MILIEU AND TRANSITIONAL LIVING PROGRAMS

The milieu is the hub and the most powerful aspect of a TLP.

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To meet the developmental requirements of this age group, an

adequate milieu includes:

(1) Abundant opportunities for the development of

continuing, engaged relationships with adults both

within and, later, outside the treatment setting.

It is crucial that these relationships occur within

a framework of guidance and feedback with the staff

members. Staff members are prepared by previous

training and by continuing supervision to listen,

understand, and integrate new findings with previous

knowledge of the child and his relationships. Staff

members must know how to respond to youth and other

staff members in a manner that furthers the

therapeutic goals.

(2) A cadre of childcare workers in the milieu, supervised

by experienced, engaged mental health professionals. The

number of childcare workers must be sufficient to allow

individual time each day with assigned youth; overall

awareness of interactions in the milieu; time for

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recreational and other impromptu groups; opportunity to

contact agencies and individuals involved in each child’s

care; time to keep records and for communication between

workers; and time for their own supervision by senior

staff members.

(3) Planned programs of life experiences appropriate to

the age, sex and interests of the individual

members.

(4) Recognition of individual differences with planning

and supervision that provides for and monitors each

child’s program on a daily basis.

(5) A support system for the milieu that provides ready

access to expertise and interventions regarding

group process, medical/nursing, psychiatric,

nutritional and administrative issues.

(6) Finally, but no less essential, there must be a

strong concerted effort to engage parents and

relatives in the program to understand the child

(and to help the child understand them) and to

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participate in planning the treatment program,

including discharge planning.

The key players in the milieu are the childcare workers;

these are usually college graduates with no specialized training.

He or she learns on the job by example and through group and

individual supervision. The childcare workers integrate children

into the program in accordance with their special needs,

modifying the program and the physical environment if necessary.

They set up the children's environment; supervise recreation as

an occasion for fun and as a learning, social experience. They

help children with daily routines such as toileting, dressing,

eating and sleeping. They guide their behavior and social

development. Like parents they often prepare light snacks and

meals, maintain a safe, clean, appealing environment, and perform

simple first aid in emergencies.2

2 Given the complexity of the tasks required of them, it is unfortunate that there is no established profession of Child CareWorker, all attempts to form such a profession being scuttled by one interest group or another. The professionalization of Child Care Workers in RT is similar to that of nursing during the Crimean War; there are committed workers and excellent care is usually provided but there are few professional standards and little opportunity for formal training or advancement. Though poorly paid, the compelling seriousness of the job impels most

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DEVELOPMENTAL CONSIDERATIONS

It is helpful to consider both the broad framework of

developmental considerations that guide TL decisions and the

issues that arise constantly and require specific action. We

have found it useful to use the psychosocial developmental

framework of Erik Erikson to remind us of the deeply organizing,

or disorganizing, issues with which late adolescents are faced.

This framework is important diagnostically in specifying

psychosocial themes and therapeutically as a basis for specific

interventions.

Diagnosis in TL is expressed both in the descriptive

terminology of the DSM (as required for administrative purposes)

and in a biopsychosocial formulation that encourages etiologic

and therapeutic attention. DSM is etiologically neutral.

However, as is evident from daily practice, it has been used to

child care workers to do an excellent job. Their work can only reach adequate levels with quality on-the-job supervision. Many child care workers are young adults, seeking direction and commitment in their own lives. The experience of learning to be an engaged, humane child care worker, committed to the care of others, is often a positive, life altering experience for the young worker.

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foster a physiological bias in stating etiology and a

pharmacological-procedural bias in planning therapy. A

biopsychosocial formulation encourages equal examination of the

full range of genomic, physiological, psychological,

interpersonal, cultural and social issues.

Day-to-day, nitty gritty issues in TL are resolved by

implicit reference to the biopsychosocial formulation and to the

broad framework of psychosocial development provided by Erikson.

Developmental themes have immediate significance, determining the

moment-to-moment decisions and interventions of staff. These

themes are articulated in terms of specific expectations,

responsibilities and rules for both youth and staff. One of the

most obvious of these day-to-day issues concerns personal safety

when the young man or woman is in the community - at work,

socializing with friends, at AA, choir practice or other

activity, or visiting family. Attaining personal safety is

viewed as an achievement; no member of TL is expected to be

capable of personal safety on admission though many loudly

declare their street-smart coolness. All members are soon placed

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in situations where both staff and youth learn more about the

level of this capacity, such as preparing for a job interview,

getting GED materials from the library, planning meals, or simply

knowing how to take public transportation to a nearby mall to buy

clothing. It is expected, from the beginning, that the young

person will plan with staff members, deciding where, when and

with whom they will be during their absence and when they will

return. They are expected to follow this plan; it is their

responsibility to call if there is a change. Agreed rules bound

this process, e.g. curfew times, persons they are not to see,

places they are not to go and activities they are not to

participate in. These may be determined by the community

(curfew), court, agency that holds custody, or by the youth and

staff members.

Other examples of day-to-day issues that expose and provide

opportunities to remove inhibitions and repair damage to ego

capacities are: weekly food shopping, money management, obtaining

and retaining a job in the community, living in a co-educational

facility and educational requirements. A less obvious but most

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important pair of issues is the capacity to realize when they

need help and knowing how to get help. This applies to situations

of immediate personal safety, to situations where they must

access community resources, and to job related problems, among

others. There are many such day-to-day issues, defined by and

responded to by preconscious reference to our understanding of

the accumulated developmental requirements and expectations of

late adolescent resident and by our understanding of the

limitation in reaching these requirements of the young person we

are addressing.

Most such issues are initially dealt with through individual

instruction and explanation to newly admitted members; later, as

inevitable problems of attitude, mood or behavior arise, they are

dealt with through house meetings of youth and staff and by

individual intervention. In every instance the intention is to

increase personal responsibility to oneself and others and to

strengthen the cottage community. Supervisory meetings of staff

members are essential to provide unity of purpose, to recognize

engagement of staff members in unhelpful but inevitable

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enactments with youth, to plan responses, and to provide mutual

support. It is helpful to objectify expectations at different

stages in the treatment process, not so much to create a cookbook

of requirements as to set the stage for discussion of

accomplishments and limitations. For example, an ability to buy

groceries and prepare meals within a budget is an overall

expectation. At the beginning level, the youth is expected to go

to the grocery store, with others, to watch and learn how to buy

groceries and to learn basic kitchen procedures. They then move

on to buying groceries, preparing simple meals, learning food

group information, food preparation and storage procedures,

buying within a budget, preparing more complex recipes and,

toward the end of their stay, planning and preparing a

celebratory meal for the cottage. Again, I must emphasize that

this is not a set of items to be ticked off on a chart; it is a

set of expectations that forms the setting of relationships and

values that can only emerge if youth and staff members engage

actively and emotionally with each other.

There is a larger sense of development that guides the

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recognition and response to this myriad of daily concerns. It

answers such questions as: What level of autonomy, independence

and behavior are we to expect of boys and girls 17 to 19 years

old? What are the developmental tasks of this age group? How

are we to think about and consider the effects of past abuse,

neglect, abandonment, separation, overindulgence, drug use,

institutionalization, adaptation through superficial compliance,

and excessive dependence? These general questions lead to

specific questions about each member of our community. How does

this young person’s disorder: Post Traumatic Stress Disorder;

Conduct Disorder; Oppositional Defiant Disorder; Reactive

Attachment Disorder; ADHD; Reactive Attachment Disorder; Bipolar

Disorder; Intermittent Explosive Disorder; Psychosis, NOS express

and determine interferences with the achievement of developmental

tasks? The question asks, in effect, what are the personality

limitations that accompany the disorder in this young person?

How do they interact with other physiological, psychological and

social factors, factors that we can address in our daily work?

This again assists us in rationally deciding which items on the

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menu of treatment options we will employ. Those options include

physiologic interventions (e.g., improved care of medical

illnesses, random drug testing, dental care, psychotropic

medication), psychological interventions (e.g., milieu program,

psychotherapy, education, family therapy) and social

interventions (e.g., participation with courts and social

agencies, engagement with community programs such as church,

A.A., employment). Many of these interventions have implications

for more than one aspect of biopsychosocial functioning.

Once we have started the process of answering these

important questions we must additionally inquire: Can we provide

therapy for broad psychological issues when we are simultaneously

responding to severe educational, delinquent and interpersonal

issues? Or are we bound by the depth of psychopathology or the

severity of injury by traumatic experiences to seek only for

improvement in immediately obvious concerns? Auditory

hallucinations must be tamed; drug use must cease; reflexive

aggressive defiance must be contained before we can usefully

address issues of autonomy, fidelity and personal vision.

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Certainly, if we are limited to one month or three months of work

with the young person, or if the only criteria for discharge is

compliance with external rules, then we have only limited

opportunity to make headway with these broader issues, though

even then there is no excuse for ignoring their continuing

importance. I suggest that the formulations of Erik Erikson

will take us a long way toward the developmental perspective we

need. Erikson is an oft-quoted but rarely read psychoanalyst

whose ideas have deeply penetrated western culture; they live in

our daily speech in such terms as identity(as in identity

crisis,gender identity,racial identityand so on) and basic

trust (as in, “he hasn’t achieved basic trust”). A restatement

of some of his ideas will specify the broad developmental

considerations that guide TL.

Erikson’s approach is epigenetic, meaning that each step and

level of psychological development depends upon and is built upon

the achievement of past steps and levels. The tasks of each

stage of development are not unique to that stage, they have been

present in earlier and will continue in later stages. It is

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simply that they are the most obvious and most crucial at a

particular point. Thus, the achievement of a balance of trust

and mistrust, a capacity to lean upon the abilities of another

and to withdraw trust when it is not earned, is a life-long

function that has critical beginnings in the first year; it

continues to be an issue throughout the life span. A solid

beginning provides an optimal foundation for the next stage.

The reader will recall that in Erikson’s eight stages there

is an expanding elaboration of:

(1) A balance of trust and mistrust with the achievement of

hope or confidant expectation during the first year, together

with

(2) A balance of autonomy with shame and doubt with the

achievement of will power or capacity for autonomous decision from

age 1-3, together with

(3) A balance of initiative and guilt with the achievement

of purpose or capacity for action limited by respect for others from age

3-5, together with

(4) A balance of industry and inferiority with the

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achievement of competence from age 5-12, together with

(5) A balance of identity with role diffusion with the

achievement of fidelity or capacity for sustained commitment from

age 12-18, together with

(6) A balance of intimacy and isolation with the

achievement of love in young adulthood, together with

(7) A balance of generativity and stagnation with the

achievement of care in adult life, together with

(8) A balance of ego integrity and despair with the

achievement of wisdom in old age.

The adolescents and young adults with whom we are concerned

are, chronologically, in stages (5) and (6). But Erikson’s

approach allows us to realize that many late adolescents in the

general community continue to have issues related to the previous

stages and give indications of moving toward the later stages.

All youth in TL have experienced disrupted families, abuse

or abandonment, mental illness and/or institutionalization; they

are likely to have significant residual issues related to the

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tasks of these earlier stages that interfere with or color later

stages. In spite of these assaults on expected development, they

all struggle in their own ways to achieve a greater sense of

harmony and competence. Keeping Erikson’s observations and

conclusions in mind, we can organize our thinking and plan our

programs by recognizing the presence and extent of the

limitations and the nature and effectiveness of recuperative

efforts.

In regard to stage (1), we often note an inability to look

to the future with confidant expectation. Positive recuperation

includes efforts to achieve closeness or identification with

staff or therapist who can encourage and support completion of

high school, cultural awareness and pride, vocational skill and

recognition and an enlarged vision of future possibilities. Our

experience is that long-term change almost invariably requires a

real family relationship in addition to the TL environment. A

“real family relationship” often involves coming to terms with

the fact of indifferent or rejecting parents while finding

alternative connection with a sibling, aunt or uncle, or foster

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family. Negative or stagnant recuperation is often attempted by

the youth through defensive indifference or blatant braggadocio.

In regard to stage (2) we note difficulties with society

derived from impulsivity or lack of will power, presenting as

impulsivity, passivity, and ease of seduction. Positive

recuperative efforts include renewed efforts at self-control in

response to confrontation and support and modeling and

identification with autonomy of staff. Negative or stagnant

compensation for lack of will power includes obsessive behavior,

the stupefaction of drug use, and preoccupation with pornography.

In regard to stage (3) many youth drift through life with a

lack of evident purpose, perseverance or grit. When these

qualities are present, competence (stage 4) can follow. Daily

life in the milieu provides a myriad of possibilities for purpose

and perseverance and for the achievement of competence:

decoration of their room; learning how to buy clothes and dress

stylishly; planning and cooking a meal for the cottage; seeking,

applying for, interviewing for and, finally, getting a job;

sticking with a job (and knowing when to quit); saving money for

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a CD player, furniture and other possessions. The key in each

instance is the provision of opportunity and gently confrontative

encouragement to act, achieving pleasure in the result. Many of

the presenting problems of youth relate to a lack of these

qualities. Failure in stage 3 includes a sense of inadequacy and,

in many, guilt when they achieve at a level unknown to their

parents or family. Chronic depression (dysthymia), lassitude,

indifference, and clinging to purposelessness are common

expressions of difficulty at this stage. With regard to stage

(4), we note both a reluctance to engage actively in school or

work and a tendency to premature closure in making decisions

about completing school or choosing a vocation. Getting a GED,

rather than completing high school or deciding to “join the

Army,” may be less the result of thoughtful consideration of

alternatives than a reflection of limited horizons and

impoverished self-esteem.

With regard to stage (5), members of TL often have a limited

ability to commit to future goals and strong ideals or even to

their own bodies and sense of self with consistency and fidelity.

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Instead, some prematurely commit themselves to enticing,

provocative immediate goals by joining a culture of drugs or

crime. A lack of belonging and a diffuse sense of self may,

again, be expressed by chronic, low-grade depression and may be

compensated for by gang membership, AWOL adventures, and

identification with delinquent peers. Here we attempt to provide

an open horizon of potentials through contact with role models

(staff and others) and by surrounding them with an environment

that speaks of aesthetic and vocational possibilities.

From the perspective of stage (6), few TL members can engage

in love relationships, that is, with lasting empathy, self-

sacrifice and commitment to others. Several of our young men

have previously fathered children and one achieved a lasting

devotion and sacrifice for his child. Although we encourage

movement toward this stage and provide preparatory guidance

through discussion of relationships, gender identity, object

choice and sexuality, we do not expect full engagement of this

stage during the TL experience.

As we consider the limitations of these young people and the

27

measures we have available to assist them, we are reassured by a

corollary of Erikson’s epigenetic approach. Although each of the

stages has a time of prominence, all of them can be influenced

toward achievement or deterioration at later times. We can

recognize the influences that have been responsible for

difficulties and we can provide new input into qualities that may

have long been damaged or quiescent by providing a strong and

encompassing program.

Beginning with hope or confidant expectation, all of these

stages are stimulated through growing relationships with staff

members who verbally express and demonstrate through action that

they can look to the future, make a plan, and have it work, in

the immediate future and, hopefully, for the more distant future

as well. From a horizon of expectation limited to a return to

the projectsand former friends, employment in an entry-level job

and nothing more, staff members struggle to restore or encourage

a vision of the future, an awareness of possibilities. Many of

these young people speak of going to college, Job Corps, or the

Army as a blind alternative to life in the projects, but with

28

little sense or stated desire to find out what these alternatives

would require or what value they might be to them. Giving shape

to these desires through discussion and by taking the young

person to the Army recruiting station to talk with the recruiter,

to college visits and interviews, we seek to move vague hopeless

urges to the level of defined but attainable possibility.

AN ILLUSTRATIVE VIGNETTE: DEVELOPMENTAL PRINCIPLES

A case example illustrating these principles and several

brief accounts that accent particular issues will be helpful to

grasp the daily reality of treatment in a TLP. 3

Hal, age 17, entered TL from his home at the request of a

public agency after his mother declared herself unable to

continue parenting him. Afflicted with severe medical problems

including sensory and motor deficiencies of the lower half of his

body, he required regular preventive care, including self-

administered bladder catheterization and suppositories.

His household had been disrupted by his father’s sudden and

severe mental illness. After several years of family

3 All case examples have been altered to protect the identity of the individuals described. In each instance, however, the basic issues and the steps taken to modify them have been retained.

29

disorganization and worsening financial hardship, his mother

divorced though barely able to sustain herself and her son. His

mother established serial relationships with other men, but none

of them made an effective relationship with Hal.

Hal experienced repeated medical emergencies and one

harrowing surgery during his school years. A pattern of

indulgent maternal care, interrupted by episodes of frustration,

anger and rejection, developed. When, in adolescence, it was

expected that he would take over many aspects of his personal

care, Hal refused. Instead, he wet himself both day and night,

suffered repeated fecal impactions and was generally

uncooperative. When his mother exploded with frustration, he

pleaded for her forgiveness and exclusive attention. Just prior

to admission to TL, Hal had a severe, penetrating bedsore

requiring hospitalization.

Because of his neurological problems, Hal required braces

and crutches or a wheelchair to ambulate. He repeatedly broke his

braces so that he could use the wheelchair, which he preferred,

instead.

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Hal’s education was fragmented and irregular. Admitted to

special classes, he was diagnosed with ADHD as a preadolescent

and placed on stimulant medication and an antidepressant with

modest improvement. His social life was also fragmented and

limited. He had no ongoing friends, alienating them with his

body odors and social inadequacy. His mother attributed many of

these limitations to brain damage that she believed he had

suffered during surgery. She flailed herself, and Hal, with

powerful feelings of guilt, anger and frustration.

Hal entered the TLP with diagnoses of ADHD, mild mental

retardation, Oppositional Defiant Disorder and possible psychotic

disorder. The biopsychosocial diagnosis and formulation included

the elements described above.

Developmental assessment presented a grim picture for

treatment planning. There was no aspect of his life about which

Hal felt a sense of confidant expectation. He had a powerful

sense of his own will power, expressed negatively in refusal to

care for his body. A sense of purpose and competence had been

deeply undermined during his preschool and school years by family

31

disruption, maternal despair, medical illness and interventions,

as well as by the disorganizing effects and unanswered questions

arising from his lack of bodily sensation and limited muscle

strength. The severity of his developmental immaturity prevented

him from making any real progress into the adolescent issues of

fidelity, identity and commitment.

The key to every treatment program in the milieu of TL is

the quality of staff member relationships. These relationships

necessarily bear many of the burdens of the youth’s past

relationships. As a partial repetition of past relationships,

they also represent an opportunity to demonstrate and challenge

the young person’s modes of expression of needs and wishes and of

defense against those same needs and wishes. An opportunity is

created to break old patterns, forge new connections and thereby

influence the internal world of the child. Expectations, self-

concepts, and values can change. The effectiveness of these

relationships in promoting change is possible because they deal

with the emotionally charged, “real” issues of daily life.

The most difficult such issue with Hal was the one that we

32

initially felt could be most easily altered, his refusal to care

for his body. Although he soon gained sufficient responsibility

for self-care to prevent a recurrence of skin breakdown or fecal

impaction, it required many months of work before he would begin

to relinquish his extreme dependence and provocation of others.

We challenged the investment he had made in body care as an

indication of love and attention and showed him, through daily

experience, how he “used” his wetting and smelliness to avoid

expression of his adolescent wishes and feelings. “Love and

attention” with his mother often meant provocation and fighting,

an attitude he continued in TL. When progress was made with him

in this area, a cascade of issues and questions emerged about the

nature of his physical problems, their implications for learning,

for adult education and employment, and especially for sexual

functioning. Many of his questions, including complex questions

about his sexuality were approached in contacts with the

pediatrician, the cottage psychiatrist and his psychotherapist.

The issues also became real when Hal obtained employment as

a file clerk on campus. His self-doubts had to confront the real

33

appreciation of his work by his employer. Arrangements were then

made for outside work with a job coach. He now was required to

get up early, take public transportation, and both save and spend

his earnings.

Hal completed high school in the campus school, attended

graduation at his home school and entered into a new phase of

work as he contemplated his further education and/or employment

and complexities of future relationships. Taking his treatment

to this point provides a sense of the work and its basic

connection to issues of development and to a biopsychosocial

perspective.

We will leave him at this point. Major questions that are

not detailed here but were also addressed concerned his

relationship with his mother, his father’s mental illness, and

the further resolution of issues surrounding self-care,

sexuality, and age appropriate relationships.

BRIEF CASE REPORTS: PARTICULAR ISSUES

Three brief case reports exemplify issues frequently seen

in TL. The first case is an example of a sadly frequent

34

circumstance, an adolescent who has lived a lifetime of

rejection and psychological abandonment. Danielle, age 17,

was admitted from a residential facility that provides

structure and containment through a well ordered but

impersonal program of group meetings, education and

medication. She had been sent to this facility by the court

following repeated determinations of “domestic violence” that

had been charged by her mother. Our meetings with her mother,

grandmother and father as well as with Danielle, exposed

longstanding jealousy, emotional rejection and control of

Danielle by her mother; the incidents of “domestic violence”

were instances of Danielle rebelling against these excessive

controls, but never with physical aggression. Her mother

repeatedly called the police and charged violence. Finally,

Danielle was removed, placed in the Detention Home and then in

a residential facility from which she was later transferred to

TL. Danielle had been and remained depressed, defeated,

inactive and without hope.

In TL she returned to work at a fast food restaurant run

35

by her grandmother where she was paid minimum wage. She had

no evident ambition or hopeful image of herself in the future.

Danielle received schooling and psychotherapy in the TL

environment and entered into positive encouraging

relationships with staff and peers. Intervention did not

alter her feelings of responsibility for her mother’s

rejection and disappointment in her. On several occasions she

allowed high status peers to lead her into degrading

situations. She had a brief relationship with an older man

who she idealized as someone “who will care for me.”

Doing well academically, Danielle moved from the TL

school to public school where she graduated. She visited

local colleges, learned about the variety of certificate and

degree programs available. In spite of her mother’s

insistence that she “live outside of Cleveland” to be allowed

to visit at holidays, she entered a local college where she

lives in a dorm. She hopes, with feeble conviction, to become

a nurse. She continues to be mildly depressed, still seeking

the elusive approval of her mother. Maternal rejection

36

throughout her life left Danielle with a stubborn, chronic

depression, an insecure sense of self worth, and a limited

capacity for competence or sustained commitment. Our efforts

in TL to counteract this influence have been only marginally

successful due, we think, to the continuing, unrelenting

rejection by her mother.

Some graduates of TL make astonishing progress against

seemingly intractable symptoms and circumstances. For some, a

new life in college is available; there, we hope, adolescent

issues of identity and attachment will have time to be more fully

resolved. Others, like Janie, choose vocational training. All

must, to some extent, continue to struggle with the results of

early deprivation and abuse. Janie, a 17-year-old girl,

abandoned by her crack-using mother in infancy, had spent her

childhood and adolescence in a series of foster homes and

institutions with no lasting personal relationships. On

admission she was distant, painfully shy, avoided eye contact,

spoke in stereotyped, formal phrases and expressed devotion to a

foreign comic book character who she wished to emulate. She was

37

obsessively concerned with cleanliness and with time but usually

looked disheveled and disorganized. She met criteria for Post

Traumatic Stress Disorder, Obsessive Compulsive Disorder and

Schizoid Character.

Over a period of a year, a combination of consistent daily

interaction with her individual milieu worker and other milieu

staff members, education in a small, supportive classroom, and

supportive psychotherapy, she was less symptomatic and became

able to interact verbally with others in unstructured situations.

Initially unable to enter the community, she first went grocery

shopping with the group, then ventured forth with peers on public

transportation. In the cottage she participated in the girls’

mutual hair care and braiding. A special triumph came with her

being hired by a local McDonalds where she became a loyal and

respected employee. She verbalized vocational and interpersonal

goals. As she struggled, she became far less stereotyped and

restricted, dressed attractively, and saved her money for

furniture for an independent living apartment and for support

during vocational training. She continued to be shy and

38

sometimes awkward, but was self directed in buying clothes,

choosing a hair-do, deciding on her post-graduation vocational

plans and setting limits for others in their interactions with

her. Her obsessive-compulsive symptoms receded without use of

medication. Jamie was able, over time and with psychotherapy and

milieu therapy, to address issues of shame, doubt and

abandonment, freeing her from disabling obsessions and

compulsions and supporting the possibility and gradual

achievement of autonomy,

Although most TL members have failed to achieve stability of

several of Erikson’s psychosocial stages, failure in finding a

balance of industry and inferiority with the achievement of

competence is most frequent and provides a helpful point of

therapeutic entry. This stage occurs between 5-12 years old,

suggesting the etiology of these problems. These are elementary

school years, when basic learning skills – reading, writing, math

concepts, and computation - are acquired. Disordered lives with

frequent moves, unstable relationships, personal doubt and little

encouragement fortify the effects of negative community attitudes

39

and inadequate educational facilities in denying them a sense of

completion and competence in a sustaining setting.

John, a 17 year old, tall, handsome young man had lost all

contact with his drug addicted and incarcerated parents. Living

with indifferent relatives and friends, he had recurrent

appearances in Juvenile Court for non-violent offences and was

placed in TL through the county agency. A few minutes with John

were enough to identify his very powerful character defense, an

attitude of self-reliance and self-control. Acknowledgment of

incapacity or weakness was difficult and was the focus of milieu

interventions. Charming and verbal, it was only when we

forcefully challenged his refusal to complete work applications

that he was finally able to acknowledge his inability to read or

to write. Similarly, he consistently was truant, slept or

refused participation in school until acknowledging his inability

to read or do basic math.

Two developments cleared a path for this basically intelligent

young man. We discovered an uncle who agreed to employ him as a

house painter. Contact with "family" and the informality of the

40

work arrangement encouraged John to participate. Once he had

money in his pocket, previously latent but powerful feelings

about unmet emotional and material needs led to temporary use of

drugs and to money management issues. When the family

connections, and his job, dissolved in recurrent family conflict,

John agreed to "try out" an innovative education program

utilizing individualized-programmed teaching techniques under

strongly structured but responsive adult direction. John

attended regularly and made steady progress in basic math and

reading. With support, John found new employment, could complete

his application forms and did well in employment interviews.

The key to change was a modification of his intense character

defense of self reliance, allowing him to acknowledge need and to

accept help. This issue continued to recur in other real life

situations, allowing progress toward further flexibility of

response and the enjoyment of his new-found competence. He

established himself independently in the community after

discharge and keeps in regular phone contact with Transitional

Living staff members.

41

CONCLUSION

We hope that the reader has been able to vicariously share

with us in the excitement of work in a Transitional Living

Program. The young people with whom we share this environment

stand on the threshold of adult life. They have suffered

medical, psychological, environmental and social insults.

Psychosocial developmental assessment helps us define the details

of threats to the foundations of adult personality functioning.

These young men and women are woefully unprepared for self-care,

social interaction, occupational choice and adult personal

relationships.

The premise of Transitional Living is that relationship based

milieu therapy, guided by psychoanalytic developmental principles,

provides an opportunity to heal these conflicted and immature young

people to a degree that can tip the scale of their future lives

toward productivity, self-esteem, and commitment. Like Residential

Therapy, Transitional Living provides milieu therapy, corrective

education and psychotherapy. Unlike Residential Therapy,

42

Transitional Living is also embedded in the urban community. It

facilitates the transition from dependent childhood to independent

living by intensive work with the conflicts, physical and social

barriers to success in making this important step.

43

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