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Posted February 28, 2005


By Jared U. Balmer, PhD
Executive Director
Island View and Oakley School

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.



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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