Hospitalized adolescents who act out: a treatment approach

The general propensity of hospitalized adolescents to act out and to become locked in conflict with the staff is well documented. The fact that these patients are adolescent and incarcerated all but guarantees that disruptions will take place, and when these disruptions reach impasse proportions, collective distress and disturbance will generally result (Crabtree and Cox 1972; Marohn, Dalle-Molle, and Offer 1973; Levinson and Crabtree 1979; Crabtree and Levinson 1980). Often the catalyst for this type of ward tension is the borderline or sociopathic delinquent. The sensitivity of these patients to injustice and their capacity to provoke abuse exacerbates the ever-present tendency of their fellow adolescent patients to rebel and oppose. This paper will provide guidelines which can help to maximize the treatability of severely acting-out adolescent patients in the hospital setting and protect the treatment program from their destructiveness. First, I will focus on a specialized unit in a general psychiatric hospital. The unit consisted of approximately 20 patients, male and female, in their teens to early 20s, with an average stay of three months. One-fourth were psychotic, one-fourth had marked problems of behavior with school, family and the law, and one-half were suicidally depressed or afflicted with other self-destructive personality disorders. Next I will explore aspects of handling the "outlaw leader"--the persistent delinquent who initiates and orchestrates a process of disruptive transformation of the therapeutic community, characterized by the dominance of frustration, provocation, and retaliation by the staff.