‘A Home for the Heart’ by Bruno Bettelheim

Bruno Bettelheim (1974) A home for the heart London: Thames & Hudson 0 5000 1113 3

Bruno Bettelheim (1903-1990) was an Austrian Jew who, before the Second World War, with his wife had fostered a girl whom he later described as autistic. He was one of many Jews rounded up and sent to concentration camps but then released in a public gesture in 1939, after which he emigrated to the US. His accounts of concentration camp life were initially vilified (1968) but he was eventually sufficiently accepted to obtain a post at the University of Chicago where he directed the Orthogenic School. Love is not enough (1950) was in effect his manifesto for the school and A home for a heart (1974) his retrospective on those experiences. By this time, the age range of those attending the school had extended to young adulthood and the focus of the book is on comparing the Orthogenic School with other mental health facilities; so the term patient is used throughout, though most of the ideas and examples relate to, and are relevant to the care of, seriously disturbed children and young people.

Key Points

• People need to believe that people with a mental illness can be ‘cured’ if they are to help them.
• Successful therapists have experienced crises which have enabled them to get some idea of what a patient might be going through.
• Only holistic approaches to treatment will succeed.
• Unsuitable buildings increase costs directly and indirectly through the impact they have on the self-esteem of residents.
• Workers need to understand the patient’s view of their situation in order to help them.
• All interactions need to improve the patient’s self-respect.
• The head should actively engage in the daily life of the residents.
• Converted buildings in urban locations where residents can feel ‘at home’ even though it is not their home are best.
• Buildings need decor to distinguish different parts and locks that keep strangers out but do not keep the residents in.
• Dormitories permitting at least 14-16 square yards of personal space to each resident are better than single or double rooms.
• Investing in quality furniture and utensils, including things that were breakable, was cheaper in the long term than purchasing cheaper ‘unbreakable’ items.
• Patients must see the institution as a place in which they can help themselves rather than as a place to which they are sent or in which they will be ‘helped’.
• Potential residents should be given enough time and experience of the institution to be able to make their own minds up about admission.
• Integrated care comes from having a single person at the centre of the patient’s care supported by two others.
• Only those staff who are prepared to stand up for residents really care about residents.
• Senior staff must offer the same quality of support to staff as they expect staff to offer to patients.
• Selection of staff must involve all those with whom they are to work.
• Key decisions must be in the hands of those who work with patients but they must be prepared to justify them in detail to colleagues and senior staff.
• Working with people inevitably involves working with issues one has oneself.
• Informal meetings are as fundamental to the support of workers as are regular formal meetings.

Content

In the Introduction, he argues that our ambivalence about people with a mental illness underlies the appalling ways in which they are treated; if we believed they could be ‘cured,’ we would treat them as normal human beings but we don’t. Yet a person with a mental illness can be cured in a total therapeutic milieu in which people have “a deep commitment to his physical and emotional well being” (p. 4). Over the years the Orthogenic School had extended its work from children to young adults, achieving an 85% success rate in terms of former residents living a normal life in society.

Therapists have to understand people in relation to those who care for them but their job is, in effect, to descend into the pit where the patient is and where they can see the world from the patient’s point of view and then offer them a way out which they may reject. However, a patient can only be cured once they are confident enough to put their foot on the ladder out of the pit and that will only happen if the therapist shows sufficient interest in the patient’s well-being in the pit to make the patient interested in what they might have to offer. While in the pit, the patient will examine every minute detail of the therapist’s behaviour for evidence of their reliability.

The most successful therapists have been through one or more personal crises which have enabled them to see situations from the patient’s point of view. For example, his experience of the concentration camp had led Bettelheim to reject anything which might enable one person to hold another in their power. On joining the Orthogenic School, therefore, he had insisted that doors remained unlocked. He had also been able to draw on his attempt to ‘treat’ an autistic girl by fostering her before the war and his earlier encounters with schizophrenia.

All such experiences of staff need to be brought together into a coherent philosophy which is put into practice in the institution; this book will look at how this was done through the physical setting, the therapy, the staff and the training.

In Chapter 1 Ambience: buildings and their inhabitants, he argues that we all function differently in different spaces and that the physical arrangements in most mental hospitals do the patients little good. Citing Tuke (1813), he argues that patients need to be given self-esteem. Initially mental patients were imprisoned; then they were subject to ‘moral treatment’ and then, as hospitals became the main focus for their treatment, the characteristics of a hospital for the physically ill were transferred to those for the mentally ill without regard for whether they were suitable for their treatment. Hospitals are often over-crowded compared with other forms of accommodation and understaffed, with restraint now being administered through drugs.

Unsuitable buildings increase costs and the much lower costs of treatment in the Orthogenic School compared with other public and private mental institutions were also in part because some staff preferred to work for lower wages in an institution that worked rather than for higher wages in one that didn’t. But these economic arguments ignore the impact the building has on the self-esteem of the patient; making mental hospitals look like prisons does nothing for them.

In Chapter 2 The “secondary gain” as therapy, he argues that the answer is not community care which is often no care at all and dismisses the argument that some patients accommodate themselves to institutional care, on the grounds that rational people normally try to make the best of any situation in which they find themselves. Rather than dismissing the way a patient has accommodated to the situation, the therapist has to understand this in order to understand the patient. Staff should also not be surprised at the perceptiveness of patients about what is going on among the staff; understanding staff reactions is part of making the best of the situation.

Dismissing those who question whether mental illness is real, he argues that those who suffer mental illness suffer from a lack of healthy, that is, self-critical, self-respect. What we call mental illness are the person’s ways of dealing with this lack. Apart from this lack, people with a mental illness are no different from other people.

In Chapter 3, Mental health, autonomy and need satisfaction, he argues that, if psychoanalysis could solve all problems, there would be no need for mental hospitals and that a key component of mental illness is competing demands which we cannot reconcile, paranoia and depression being two different responses to such competing demands. Unfortunately, in traditional mental hospitals, too much emphasis is laid on keeping patients safe and not enough on supporting the staff and facilitating the patient’s recovery.

Improving self-respect involves providing bathrooms and toilets, where patients care for their physical bodies, that convey positive messages about them. Similarly, responses to violence, whether in terms of physical features or personal responses, need to demonstrate respect for the person in the middle of the outburst and those who might be harmed by them rather than lower their self-respect. Finally, pandering to a patient’s delusions does nothing to improve their self-respect.

In Chapter 4 Ambience: the structure of life, he discuss how institutionalised living gives none of the satisfactions of family life, where eating and bathing can be pleasures, and how institutional rules often militate against staff showing genuine care for patients. They solved the problem of locking away things that might be dangerous to a child by locking them in a locker in the child’s room which the child could inspect at any time. Otherwise nothing was locked away. But this itself was part of the evolution of the Orthogenic School and all good institutions evolve anyway.

In Chapter 5 Needed: an integrative model, he considers the various models used for institutions, from the cottage homes to wards, before arguing for the integrative model of the Orthogenic School which Henry (1957) described as a `“small republic or a large family, depending on the point of view”. He placed himself as the central figure always accessible to the children and therefore someone they could come to know and predict. This was not just a matter of being available to answer questions or deal with complaints but of actively sharing in the children’s leisure when they could make casual enquiries without the formality of coming to the office. The same opportunities were available to the staff.

He argues for urban locations where even those that need an escort can go out into the community and where the act of dressing up to go out is part of reinforcing the person’s sense of worth. Keeping people in touch with the realities of life outside the institution is essential for their rehabilitation.

In Chapter 6 The eye of the beholder: architecture and locale, he describes how a building conveys messages to its inmates and how, in his haste to change the messages the building conveyed, he had failed to understand the old messages that parts of the building conveyed or to explain his intentions fully to the staff. This had unsettled the children who were confused by the new messages.

He notes that the most impressive features of institutions are usually not intended for the patients and that all features of an institution can convey messages to the inmates. While not being ‘home’, it must be somewhere where the patient can feel ‘at home’ and, even without locks, it must have clear boundaries.

In Chapter 7 The silent message: the unicorn and the phoenix, having argued for the conversion of old buildings rather than the building of new, he outlines how that happened over the years at the Orthogenic School, making features of the old building features of the new, using art in a variety of ways, in particular a twice life-size sculpture of a reclining female figure, and attempting to redecorate a hall with a large staircase. He also discusses the smell of a building and its feel when touched.

In Chapter 8 The silent message: situational symbolism, he discusses the importance of using the decor to create landmarks which identify places and of keeping everything open, with locks mainly used to keep strangers out. Of course, things did get stolen but the cost of compensation over the years was 0.0005% of the budget, rather less than the cost of locking things up!

He argues that, though there were occasional assaults, they were never serious enough to justify locking anyone up and they had no suicide attempts even by patients with a history of suicide attempts. Once patients understand that the purpose of locks is to protect them, not confine them, they reinterpret other features such as safety screens as protective also.

Similarly, working with outside agencies to help them to interpret the occasional false alarm as part of a child’s need for reassurance also reassured the child.

In Chapter 9 Living room and Lebensraum: spatial messages, he describes the visitors’ room, which is the first room a child will enter; this contains a throne, a cradle, a dolls’ house, a seahorse and a library all which the child may use. Interestingly, while ‘normal’ children would play with the dolls’ house, those destined for the school did not. The room was also large enough for a child to keep their distance if they wished and for staff to gain clues as to the distance the child wanted to keep. When family come to visit, they meet in the same room.

New admissions need to form an opinion of ‘the boss’ and so he would always meet the child and seek to make the child the centre of attention, inviting the child into his office during the first or second meeting where others would not become a centre of attention.

In Chapter 10 Dormitories: group living and ‘territoriality’, he argues that the most important spaces are the patient’s spaces which should not be single rooms, both because many patients do not prefer this and because they too easily become a place of retreat from the world where they can be overlooked by staff. Double rooms also create problems; for example, when one resident has a visitor, what does the other resident do?

They ended up with groups of six or seven living together, but with other rooms into which children could withdraw if they wanted, normally with a member of staff because they would only withdraw if something was troubling them. Around 14-16 square yards was needed for each person’s personal space. Children varied in how they marked the boundaries of their personal space but they generally sat on their beds while ‘visitors’ sat on chairs in their personal space. Furniture was custom-made in consultation with residents and, though more expensive, was more economical because it was cared for and lasted longer than conventional furniture. Children’s personal possessions were initially kept in metal chests but eventually drawers were added to the beds for children who felt safer sleeping on top of their possessions. The way children decorated these personal spaces often told you a lot about what they were feeling and thinking.

In Chapter 11 Dining room and bathroom: trauma and treatment, Bettelheim argues that food should always be available, not just at set times, and that tables should be circular because they promote more interaction than rectangular tables. Tablecloths were used for special occasions and knives were only withheld from patients on the rare occasions when they had evidence that they might be misused. If patients threw food on the floor, a staff member, rather than a domestic, cleared it up; utensils were deliberately not made unbreakable because that implied the patients would want to break them.

Patients were involved in choosing the menu and also the fabrics and furnishings and, while this tended to mean patients cared for their environment, that was never turned into an expectation. For one thing, the cost of letting a patient take out their feelings on the fabric of the institution was far less than the cost of treatment sessions to deal with those feelings. These feelings then needed to be addressed in the day-to-day interactions with the patient rather than in specific treatment interventions.

He decries the utilitarian bathrooms and toilets, often serving both purposes, in institutions, arguing that they should be comfortable and attractive places that convey respect for the patient. Their toilet doors were lockable but not completely full-length so that a patient could have privacy but also not be inaccessible should they seek to harm themselves. He concludes with an example of a girl whose difficulties with the toilet and bathroom were symbolic of the emotional abuse she had suffered and how she was helped to deal with these.

In Chapter 12 The I of the beholder: pre-admission visits, he argues that a patient must be given time to get to know the institution before they are admitted; only in this way can the patient make their own decisions about how to respond to the institution. He describes how a seriously anorexic girl arrived believing she had been ‘admitted,’ how he insisted she drink a glass of liquid and then let her leave to convince her that it was her choice and that he did care for her. She came back the next day.

He stresses that patients must see an admission as a way of dealing with their feelings about the situation in which they find themselves, not because other people think it is a good idea or because they are going to be ‘helped’. Because they can never be sure they can keep most promises, the only one they make is that staff will do their best. Prospective patients are only introduced to staff, not to other patients, at this point and eventually they are asked whether they wish to proceed with the admission. Some agree and regret it, running away later, but they are always accepted back without recrimination – and they always returned.

In Chapter 13 Receiving the newcomer: a social transition, he describes how, with limited turnover, applications were only accepted when a vacancy was pending and then only in consultation with the staff responsible for the group where the new admission would be placed. Those who met the prospective admission during the pre-admission visits had to decide whether they were prepared to accept the patient and, if so, purchase a welcoming gift for the new patient as well as prepare their personal space so that it had no reminders of the previous occupant.

The patients would be informed of the new admission and given basic information about them and they might discuss among themselves or with staff how best to respond to the new admission. It was important in these discussions to convey that the arrival of a newcomer did not mean that attention would be diverted from the existing residents, even though the newcomer might need more time initially.

In Chapter 14  From pilgrimage to psychoanalytic setting, he discusses earlier attempts to ‘cure’ mental illness, pointing out that many of the activities undertaken would be generally beneficial to a person. He stresses the importance of security, telling the story of a man who had been emotionally abused as a child and found refuge and peace, though not treatment, as the gardener of a mental hospital, and emphasising that no-one who has known the patient previously is allowed beyond the visitors’ room so that the patient can feel secure in the Orthogenic School.

However, in many institutions, patients get security but not treatment; they need a total therapeutic milieu, such as those attempted by Aichhorn (1951) and Redl and Wineman (1952), in which to re-organise their lives.

In Chapter 15 Experiments in total treatment design, he describes how the Orthogenic School had originally treated people with learning disabilities and then with physical disabilities and epilepsy before a decision was made to focus on childhood schizophrenia and Bettelheim had been appointed. He recalled that, when he had fostered the autistic girl before the war, he had been irritated by the psychiatrist’s attitude to what they were offering and so he had re-organised the Orthogenic School to involve all staff and try to avoid any hierarchy. However, particular patients gravitated to certain staff more than to others and this led them to realise that they had to know more about the specific strengths of particular staff in working with particular children.

In practice, helping staff to understand themselves contributed to creating the therapeutic milieu. For example, feeling physically good about oneself is an important part of feeling emotionally good about oneself and so staff who did not consider their own or the patient’s physical care as important as their emotional care were unable to create a total therapeutic milieu.

In Chapter 16 Staff organization and unity, he argues that the traditional structure of psychiatric hospitals militates against any commitment from worker to patient; instead, institutions define what the patient is receiving by who is giving it – casework from a caseworker, psychoanalysis from a psychiatrist or nursing from a nurse – and, if therapy is to be given, that is seen as an extra task on top of the existing ones.

Unity of treatment does not come from uniformity or the absence of status hierarchies but from the same worker responding in different ways to the different needs of patients and sharing with other workers a common understanding of the patients’ needs even though each worker may meet those in slightly different ways. To ensure this, they provided for each patient a trio of staff, a personal counsellor, a deputy counsellor and a teacher, the personal counsellor being selected during the pre-admission visits and remaining the centre of the work with the patient. He notes that personal counsellors always wanted to do the best for their patients but suitable help was rarely available from specialists or from publications which tend to gloss over the struggles that go on to understand a particular patient.

In Chapter 17 Common sense organized, he discusses studies of the Orthogenic School, notably the paper by Henry (1957), disagreeing with him that he permitted autonomy to staff and arguing that workers gained autonomy through standing their ground and justifying their actions. He also disagrees that losing workers involves losing their training; rather it involves losing the relationships they have developed. In standing their ground and making their own relationships, the workers were modelling what the patients needed to do to recover. They will only do this if they believe something is important and they will only make their own relationships with patients if they do not rely on others to tell them how to do it. If things turn out well, both they and the patient gain; but if they have just been following orders, neither they nor the patient gains because the relationship has not been strengthened.

Staff must be able to gain support from other members of the team who are secure enough in themselves not to be jealous of another’s successes. Jealousy may arise from patients as well as other staff members and, if unacknowledged, may turn into blame and interrupt the flow of support. Similarly, refusing to acknowledge an error and blaming the patient may break the flow of support to the relationship with the patient.

Senior staff must provide the same quality of support for the workers that they expect the workers to give to the patients.

In Chapter 18 Staff selection – in depth, he discusses new staff, noting that the second door they pass through is unusually decorated and they almost always comment on this; in fact, not remarking on it could be taken as a sign of insecurity about the place. New staff are expected to familiarise themselves with the work of the school by reading published material about the school and then write, as part of their application, an autobiography indicating what experiences in their lives prompted the application. The school is interested in honesty and non-destructive self-criticism.

Everyone is brought into the visitors’ room just like a patient and every member of staff, including domestic and support staff, is interviewed to ascertain why they want to work in this environment so that, if they do find themselves clearing up after a patient’s outburst, they understand that that can contribute to a quicker and less expensive recovery for the patient.

The school’s low turnover partly gave them the opportunity to take time over selection and, while those who had had a disturbed past were not normally suited to the task, those who had no experience at all of mental upset were often unsuitable too because they did not have sufficient experience to be able to imagine what it might be like to be a patient.

Applicants then spent a number of shifts working with patients which enabled them to come to terms with the realities of the work and gave the staff and patients an opportunity to appraise them. A negative response from staff would lead to rejection and one from patients to careful consideration with staff. Even with all this care, not all applicants were able to accommodate themselves to the demands of the school, often because they could not give the personal commitment to others that the school demanded.

In Chapter 19 Opening up to the patient, he argues that a total institution has a powerful impact for good or for ill. To have a positive impact, staff have to have the inner self-confidence not to withdraw or intellectualise under pressure from the patient but to respond to the patient in the here-and-now. Interestingly, applicants who had undergone psychoanalysis tended to do less well than those staff who underwent it after they had left and went on to other jobs. He stresses the importance of a shared journey for worker and patient, not  ‘us’ and ‘them’, and also that workers who cannot make that journey have to leave.

He then describes some of the experiences of staff on the way from being beginners to accepted members of the team.

In Chapter 20 Staff: joining the community, he discusses the impact of living-in on those staff who lived in and were therefore available to patients all the time. Living in the same building as the patients demonstrates that the building is worth living in but it must have status – including not being confined to low status staff – and staff must not be abandoned by senior staff in the evenings and at weekends. Some could not acclimatise to living in and would leave but others would begin to personalise their accommodation and often became more interested in helping patients to personalise their personal space.

Those who did not live in often went through a period of dropping in more often than necessary before settling on a more balanced routine while those who lived in would often move out into the surrounding area when the time came.

Professional and ancillary staff would routinely discuss what was going on and what needed to be done informally as well as in a monthly meeting. These were important when, for example, maintenance staff were repeatedly called to deal with malfunctioning equipment caused by disturbed behaviour or domestic staff had to understand the importance of particular personal possessions to patients. But when the staff saw the improvement wrought in the patient, they could share in the personal satisfaction which is a necessary motivation for everyone working with disturbed young people.

In Chapter 21 The total involvement of staff members, he argues that, while the key decisions about patients should be taken by those working most closely with them, those decisions should be the subject of detailed scrutiny by colleagues and senior staff to ensure that the reasons for the decision are clearly understood, are not based on fears or personal biases and are accepted by all. Part of the process is helping the worker to see the world from the patient’s point of view so that the decisions make sense in terms of the patient’s world view.

He illustrates this with an extended account of how a worker’s decisions in the case of a patient called Dana were based on the worker’s world view and failed to take account of Dana’s world view with abusive consequences for both. He stresses that, while on the one hand not repaying aggressive responses with aggression defuses their power, on the other not responding at all amounts to a failure to acknowledge the patient’s communication. He points out that violence from patients is most often directed at the staff who mean most to them and therefore that staff should respond in ways which demonstrate their acknowledgement of the relationship and the feelings that underpinned the violence.

Dealing with patients’ emotions is emotionally exhausting for staff and they need continual support, not least to recognise that, however devoted they are to a patient, it may take many years for the patient to acknowledge the reality of what they are offering.

In Chapter 22 Reintegration: the staff member against himself, he discusses the ways in which relating to patients can affect workers’ understandings of themselves and their own experiences. He draws on workers’ accounts of how long it had taken them to understand the impact patients’ interactions were having on them which sometimes led to greater understanding of the impact patients’ interactions were having on others. Senior staff had to support this, developing understanding of themselves and others.

A worker is only able to acknowledge their own contribution when they can give credit to others, not just the patient for what they have accomplished but also colleagues for the ways in which they have supported the patient and the worker; at the same time colleagues need to acknowledge what the worker has done. As head he had found that quiet praise, outside the ear of the worker’s colleagues, was more effective than public praise.

In Chapter 23 Personal change and professional growth, he describes how those who came to work at the school often developed in ways which enabled them to make even greater progress in their chosen professions. Others, however, found they were unable to cope with the emotional demands made by the patients and would normally, citing hours or pay. Those who remained had generally successfully navigated a crisis in their understanding of themselves and their relationships with the patients six months to two years after their arrival.

In order to chart staff members’ progress, he had invited a number to make drawings of aspects of the school which he discusses. He then relates these to discussions he had had with staff as they tried to relate to what the school was attempting to do.

Drawing on research by Wright (1957), based on Stephenson (1953), identifying four stages in the professional development of residential child care staff – observation, intrusion, participation and participant-observation, he observes that workers do not progress through these stages evenly or uniformly and relates them to the experiences of staff at the school.

In Chapter 24 The inward journey, he stresses that the worker’s own learning has to be complemented by informal learning from colleagues, perhaps over a supper after the children are in bed, or through the regular anecdotal reports on the patients which enabled workers to put their thoughts on paper, which other staff might read and which might also be discussed with patients.

He stresses the importance of informal meetings, some of which became more formalised over the years, of shared occasions and of the afternoon meetings between all the patients and staff and discusses some of the issues that might arise in those meetings.

In addition, there were five formal staff meetings a week the proceedings of which were recorded and he uses extracts from those records to illustrate the issues that might be discussed at such meetings.

Discussion

This is one of a handful of texts, the study of secure units by Blumenthal (1985) being the most notable UK example, to address all aspects of child care from the design of the building through the fabric and furnishings and the processes of care to the support and development of staff. Whether or not one agrees with the approach taken, the questions it raises about how best to provide residential care will repay study by workers, managers, policy makers, teachers and researchers.

His arguments that those best placed to help people in a crisis are those who have experienced some sort of crisis in the past have been supported in variety of ways. Maas and Kuypers (1974) found that those who had experienced stress in the past were more able to deal with stressful situations later in life, and Gilligan (1993) found that personal development was often prompted by a personal crisis.

In stressing the importance of patients’ self-respect, he is echoing the much earlier philosophy of  ‘moral treatment,’ which he confuses with ‘moral management.’  ‘Moral treatment,’ which was invented by the Frenchman, Jean-Baptiste Pussin, was all about raising patients’ morale and was the term adopted to describe the early work of the Quaker Retreat at York, where similar attention was paid to the built environment. ‘Moral management’ was the term coined by John Kitching later on to describe the widely used management of patients by rewards and punishments (Digby, 1985).

In making himself readily accessible to the patients, he puts into practice what King et al. (1971) found was crucial to quality care, the head modelling to staff positive interactions with children. He also implicitly agrees with Cawson and Martell (1979) and Blumenthal (1985) that meeting children’s needs does not require closed conditions and that even dangerous behaviour can be managed successfully in open conditions.

His arguments against single or double rooms tend to be borne out in practice by the fact that Millham et al. (1975) found no evidence that dormitory living prevented quality outcomes of care, though I am unaware of any research specifically supporting his arguments that paying more for quality furnishings and utensils speeds recovery.

Though family involvement is now regarded as a key feature of quality care (Taylor and Alpert, 1973; Fanshel and Shinn, 1978), his arguments for excluding family from the care of children may have some support from the finding by Wiener and Wiener (1990) that a very small number of parents consistently fail to act in the best interests of their children.

His argument for something akin to the keyworker system (Residential Care Association/British Association of Social Workers Study Group, 1976) has found little favour outside residential care in the UK, not least because the ‘professional’ relationships which he criticises in other mental health facilities have dominated UK child care in spite of the evidence from, for example, Tizard (1977) that such relationships are damaging to children. Indeed, the most successful out of home care, whether by adoptive parents, foster parents or residential child care staff has always been characterised by the personal commitment to a child, which he regards as essential in anyone seeking to help a disturbed child or young person.

In arguing that senior staff should provide the same quality of support to staff as they expect staff to provide to those in their care, he sets a standard which few senior staff in the UK would be expected to attain and it would be rare, given the routinising of appointment procedures, for children in care today to be given an opportunity to comment on the suitability of staff coming to work with them.

Similarly the idea that a key feature of staff support should be undocumented informal meetings would be a bureaucrat’s nightmare while the idea that therapy should focus on day to day lived experience and not on ‘key’ events in a child’s life would leave most therapists with nothing on which to work.

His account of how a worker becomes effective and his suggestion that this takes up to two years has general support in more recent research into the development of child care workers (Anglin, 1993).

The key omission from this otherwise comprehensive text on how to manage a therapeutic milieu is any discussion of how patients’ departure from the school was handled. Though he claims that 85% were living ‘normal’ lives, he does not say where they went on departure and what other factors in their lives might have contributed to this outcome.

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