Psychotherapy in residential treatment: historical development and critical issues

In a time of concern with policies of managed care, more limited financial resources, and reduced lengths of residential treatment for troubled children and adolescents in the United States, we seem to be confronted ironically with an ever larger number of children who are growing up in circumstances of social dis-organization and personal despair. Faced with this dilemma, considerations of issues related to the provision of therapeutic services within residential treatment were provided by an examination of the historical development of the concepts of the milieu and residential care in the United States. The historical review revealed how the emergence of differing theories of psychotherapy has influenced the creation of various models of residential care. Several tensions have persisted over the years in the effort to provide therapy services within the broader residential setting. Behavioral and cognitive-behavioral methodologies currently have come to the forefront in many aspects of milieu treatment in group care for children and adolescents in the United States. This article concluded with a critique of some potential impacts associated with those perspectives on individual and group treatment and on our views of the individual and culture in general. This discussion did not attempt to provide answers to all the stresses that can emerge in a residential setting that strives to provide a range of mental health services, nor was it intended to present an exclusively rejecting, strident criticism of the medical model or behaviorally oriented therapies. The intent was to point out some of the limitations of relying exclusively on those perspectives and to show that an amalgamation of treatment models can have real consequences for children in group care. A continued awareness of those potential consequences is essential to mitigate their potentially antitherapeutic effects.