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THE ROLE OF THE THERAPIST
WITHIN THE GESTALT OF A CLINICAL RESIDENTIAL SETTING
By Jared U. Balmer, PhD
Executive Director
Island View and Oakley School
jbalmer@ivrtc.com
In most cases, the placement of a child in a
residential treatment setting is implemented after one or
multiple failures in outpatient therapy. The weekly visit(s)
to the therapist could not effect desired behavioral changes
which resulted in the youth needing a more restrictive approach.
In addition to formal therapy, delivered by
a professional, a residential treatment setting uses additional
forces to establish the change process in the child. In addition
to the single dyadic relationship between child and therapist,
multiplicities of other relationships are called into play.
Those relationships are forged from a number of delivery systems
including, but not limited to the educational processes, the
structure of daily living activities, recreational and leisure
activities, a regimented and predictable environment, a well
thought-out therapeutic milieu, and vigilant oversight of
possible medical interventions including psycho-pharmacological
approaches to behavioral change. The totalities of all of
these building blocks produce something more than the sum
of its parts. They produce the gestalt of the overall program.
On occasion, parents and referring professionals
myopically focus on the therapist's "power" to effectuate
change in the child. By doing so, they undervalue the gestalt
of the program and "place all the chips" on a single
magical individual therapist.
Clearly, the literature speaks volumes of the
overall importance of the fundamental dyadic relationships
between the change agent and the child. In reviewing the professional
literature, Eisenstein (1994) and Marmor (1994) wrote extensively
about the power of the change agent. The data indicates that
the dyadic relationship is a better indicator of outcome than
the therapeutic modality employed by the therapist. That is
to say, the relationship between therapist and client is more
important than whether or not the therapist utilizes Transactional
analysis, Rational-Emotive Therapy, Neuro-Linguistic Therapy,
Rogerian Counseling, Cognitive-Behavior Therapy, or any other
modalities for that matter. While these findings are supported
by a host of researchers (Bergin & Lambert, 1978; Beutler,
1979; Lambert & Bergin, 1994; Rachman & Wilson, 1980;
Gaffan et al., 1995; Dobsen, 1989; Robinson, Berman &
Neimeyer, 1990), many clinicians embrace the latest "hot
brand" of therapy in search of the "holy grail"
or the "magic bullet." The exception to these findings
is that behavioral techniques have been found to be highly
effective in the treatment of phobias and panic disorder (Asy
& Lambert (2002). What all the researchers agree on is
that fact that therapy works. In essence, when it comes to
psychotherapy, it is the nature of the dyadic relationship
that towers over the applied technique.
But, if residential treatment is called for,
is it that simple? Do we simply hook-up Johnny with Suzy Magic
or Joe Wonderful and never worry about the gestalt of the
program? Not so. Such logic would suggest the child simply
needs a place where he has great difficulties escaping the
efforts of establishing a productive therapeutic relationship.
Such practice would lead to "programmatic ware-housing,"
while Suzy Magic or Joe Wonderful work their magic.
In the minds of most responsible change agents,
not taken by a narcissistic, grandiose overrating of their
skills, the value of a sound, well thought through, and dynamic
therapeutic milieu is paramount to the desired outcome. Such
change agents understand the reality that the therapeutic
milieu, the gestalt or program if you will, "allows"
the therapist to be more effective than an outpatient therapist
who does not have a 24-hour a day structured, controlled and
predicable milieu available. In other words, if change is
principally based on the creativity, whit, genius, and applied
techniques of the therapist, than the credit for such change
should not myopically be accredited to the therapist alone,
but shared between the dyadic relationship and the milieu
with all the multiplicities of one-on-one relationships across
a number of staff. In addition, a witty, clever and dynamic
therapist who conducts individual therapy in a vacuum of the
larger therapeutic milieu is not the optimal change agent
in any residential setting. No amount of communication and
sophisticated articulation of clinical data to parents and
referral sources can hide the fact that such a therapist is
playing in the "bush-league."
Moreover, recent investigations using meta-analytic
techniques, Asay & Lambert (2002) along with other researchers
assert that the therapeutic relationship between client and
therapist accounts for 30 percent of the change, while extratherapeutic
variables, such as the environment, motivation, etc., count
for 40 percent of the change. The residual 30 percent of the
variables are evenly divided between placebo effects and techniques.
Asey & Lambert (2002) assert that while "some practitioners,
especially the inexperienced, imagine that they or their techniques
are the most important factor contributing to outcome, the
research literature does not support this contention."
Because many residential treatment environments
are highly controlled around the clock, one may not want to
underestimate the role of the therapeutic milieu with its
multiplicity of relationships. It is not a stretch to assume
that the most potent therapeutic approach in a residential
setting is based on the dynamic relationships of the client
and therapist, along with other important relationships that
are being nurtured on a daily basis with a number of staff.
These other critical relationships with direct care staff,
educators, and others can not fully come to bear in the absence
of a vibrant therapeutic milieu.
Assuming a child is offered two hours of individual
therapy per week, what impact or role do the remaining 166
hours of the week have? To suggest that the change process
pivots on the back of the therapist is a horrible over-simplification
and misinterpretation of the literature. Trieschman (1969)
argues that "the child-care worker is the most important
figure of the child in the institution." He goes on to
ask the questions: "Are the events and interactions of
the day thought of merely as time-fillers between psychotherapy
sessions, or only as providers of life's necessities such
as eating, sleeping and recreation?"
Our own research validates Trieschman's assertion.
Over the last eight years Island View has administered an
exit questionnaire, in which we ask the program graduates
to list one or more people that were of greatest impact in
their change process. Aggregated findings show that while
the primary therapist is mentioned 75 percent of the time,
child care workers are mentioned 100 percent of the time.
What is equally important is that many graduates routinely
list some of their peers as having played an important role
in the healing process - what a novel idea. My own formative
research would suggest that other residential treatment facilities
show similar results.
Residential treatment is at its best when a
multi-disciplinary staff, along with a therapeutic, supportive
milieu of peers, all work together to impact each program
participant. Each discipline and sub-program within the therapeutic
environment must make a contribution to the change process
of each individual participant. This gestalt of residential
programming is bigger than the sums of all its parts.
Bibliography
Asay, T. P. & Lambert, M. J. The Empirical
Cause for the Common Factors in Therapy: Quantitative Findings.
In Hubble, et al. (2002) The Heart and Soul of Change: What
Works in Therapy. American Psychological Association. Washington,
D.C.
Bergin, A. E., & Lambert, M. J. (1978). The Evaluation
of Therapeutic Outcomes. In S. L. Garfield & A. E. Bergin
(Eds.), Handbook of Psychotherapy and Behavior Change: An
Empirical Analysis (2nd ed., pp. 139-189). New York, Wiley.
`
Beutler, L. E. (1979) Toward Specific Psychological Therapies
for Specific Conditions. Journal of Consulting and Clinical
Psychology, 47, 882-892.
Eisenstein, S., et al. (1994) The Dyadic Transaction: An Investigation
into the Nature of the Psychotherapeutic Process. Transaction
Publisher, New Brunswick, U.S.A.
Hubble, M. A. et al. (2002) The Heart and Soul of Change:
What Works in Therapy. American Psychological Association.
Washington D.C.
Lambert, M. J., & Bergin, A. E. (1994). The Effectiveness
of Psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.),
Handbook of Psychotherapy and Behavior Change (4th ed., pp.
143-189). New York; Wiley.
Marmor, J. Psychiatry in Transition. Transaction Publisher,
New Brunswick. U.S.A.
Rachman, S. J., & Wilson, G. T. (1980). The Effects of
Psychological Therapy (2nd ed.). New York: Pergamon Press.
Trieschman, A. E., (1969) The Other 23 Hours. Aldine de Gruyter,
New York.
Copyright ©
2005, Woodbury Reports, Inc. All Rights Reserved.
(This article may not be reproduced without written approval
of the publisher.)
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