Bruno Bettelheim wrote a considerable amount about the work of the Orthogenic School. In this paper his successor provides a useful summary, overview or snapshot of the Orthogenic School. I’m not aware of a similar paper by Bettelheim.
The Sonia Shankman Orthogenic School:
Psychodynamic Milieu Therapy in an Educational, Residential Setting
Jacqui Sanders International Journal of Therapeutic Communities, Vol. 6(4). 1985
ABSTRACT: The Sonia Shankman Orthogenic School of the University of Chicago is a long term residential treatment institution for children and adolescents, practicing psycho-analytically oriented milieu therapy. As part of a University, it has a three-fold commitment to service, training and research. A critical aspect of this commitment is the maintenance of the school as a model of a particular kind of residential treatment. The purpose of this paper is to describe this model. The description will use both example and conceptualisation. Since vignettes used will be for the purpose of describing the therapeutic actions of the milieu, they will not contain a history of dynamic formulation of the students involved.
Kate came to us when she was just 17 years old. The previous spring, at the end of her Junior year in high school, which she finished with honours, she had told her parents that she could not continue going to school. Though there had been some evidence of bizarre behaviour prior to this, her announcement came as a shock to them. She had begun to act like a severely autistic girl that she had seen at her sister’s school and had had some hallucinatory experiences. The psychiatrist whom they consulted recommended immediate hospitalisation and subsequently residential treatment at the Orthogenic School. In our first interview Kate sat without saying a word. She held her hands in a stylised position throughout. It was reported that she had read Home for the Heart, a book about the School, and wanted to come. This was critical since, after age 14 we do not accept any student who does not want to come. In the hospital she had already begun to be silent for very long periods of time interrupted by fits of wild screaming and flailing. She had also begun a pattern of eating only measured portions of particular foods designed to have her slowly lose weight. For a short period she enjoyed the indulgences available at the School. In our effort that the students feel both that they are worth care, and able to get it, we provide a great deal of nurturing. This stopped, however, apparently when she realised we were not an all-giving heaven. She crouched in a corner, or looked out a window, apparently engaged in hallucinatory reverie, for over a year. She would not sleep in her bed and would sometimes scratch herself, particularly during the night, and usually with a pen. She would go wherever her group went but would not participate in their activities. Her group consisted of her and 5 other girls ranging from pre-adolescent to adolescent and in disturbances from autistic to neurotic. There were periodic outbursts of screaming and running from the room, alternating with violent flailing and head-banging. An adult (counsellor or teacher) was always present. We held her to prevent her from hurting herself. When screaming stopped there was an outpouring of talk. She was articulate about what was bothering her: memories of the past, especially what was difficult about her past, and what was bothering her in the present. She told us that she was trying to grow small, to recapture a good past, to retreat into a shell and to be like the autistic girl whom she perceived as a model of passivity and perpetual dependency.
We, therefore, made sure that she ate enough. Her counsellors would persist and fight with her to make sure she maintained a minimal weight. Though she, much of the time, isolated herself, she was always in the company of others. Though she could not accept our nurturance, we persisted in providing it to fulfil her basic needs.
About one and a half years after admission, we recognised that the episodic outbursts were precipitated by some perceived inattentiveness on the part of her counsellors or teacher. We concluded, thereby, that she needed to have at all times a staff member near enough to her so that she could hold on or be held onto. By then she not only talked more with us, but wrote in her notebooks voluminously – all the while she ate with much struggle. This situation persisted for about one and a half years. It also became apparent that when she was permitted to eat less than she should, she would become more upset, withdrawn and agitated. We then began an even more vigorous insistence that she eat enough, not just to maintain a minimal weight, but that she eat enough to gain and maintain an optimal weight. With this very clear posture (effected over several weeks with some drama) her fight to retreat and grow smaller ceased and she then began to use her energies for getting what she needed and subsequently integrated and grew. Her outbursts of screaming also came to an end. During the last episode when I was present, she began to yell at me and simultaneously scream, rather than wait and be rational after the episode. The integrative process had started.
Soon thereafter she began to collect stuffed animals – to represent different aspects of herself: “Mr Bear” was security and protection; “Merlin” was a rabbit of gentleness; a hand puppet lion called “Bite” represented aggressiveness; a large lion represented the clash of ambivalent feelings; a monkey represented integration; later, she had “Maul” a bear hand puppet; and, finally, a leopard called “Stink” to represent budding sexual feelings. She was very articulate about the meaning of these animals to her.
From this point on she was able to more and more accept care and then provide it for herself; be able to express her feelings and then use her understanding of them to act in life and get what she needed.
She came to us in 1975 and left in 1982. She has been taking University courses successfully, has weathered the cancer and death of her mother, and has begun to date a variety of young men. She has not had a recurrence of the breakdown or of any of the extreme symptoms.
To understand the milieu that interacted, we believe, very beneficially with this young woman, it can be useful to view it in historical perspective. The Orthogenic School came into existence in about 1951 when Dr Josephine Young of Rush Medical School decided to have a laboratory for her students to study children with behavioural problems. Some of the parents of these children wanted a place for them to stay at night and so the residential component was begun. Several years later when Rush Medical School became a part of the University of Chicago, so did the Orthogenic School. Since it was begun as a school, it came under the Department of Education where it has remained ever since. Until the forties, the main research that came from the school was in the area of education, particularly in remedial reading, carried out by Helen Robinson. Bettelheim (who directed the school’s work from 1944-1973) defined the population more narrowly to exclude children with organic complications and/or mental retardation. His work, in collaboration with the staff, was explicated in Love Is Not Enough. It focussed attention on the details of everyday life, attempting to understand their significance and how to arrange them so as to be growth including. This understanding was informed by principles derived from psychoanalytic ego psychology and progressive education. In the 50s there was a focus on work with autistic children, though this was only a small part since at no time were there ever more than one sixth of the population diagnosed autistic.
In 1952 a new building was built permitting an increase in the population from 32 to 40 and a physical plant designed for the purpose of residential treatment. Another addition was made in 1965 to be used as an adolescent unit and allowing a population of 52. For a variety of reasons, the unit was not workable and so we began a process of gradual reduction to our current capacity of 40, which we consider to be optimum for this kind of organisation.
The therapeutic milieu of the Orthogenic School at this moment in its history consists of the following four components: a human environment, a physical environment, a theory and a therapy.
The human environment consists of the following: the Director and associates (which are one Associate Director and two consultants); the staff (which are 16 counsellors, 2 head counsellors, 6 teachers and 3 social workers); a support system (which comprises 15 kitchen and cleaning people, 3 office people); and the University of Chicago personnel. The physical environment consists of a U-shaped plant with one wing for dormitory life and one for school life, with many mutually used facilities. It is a combination of old and new, with much conscious attention given to the rationale of its design. That is, we want it to look and feel like a place for people who are loved and respected. The spaces are clearly defined as to function and provide means of protection and supervision so as to be supportive rather than punitive and restrictive. The theory used to inform our actions is that of psychoanalytic ego psychology, that is, in trying to understand any issue, in developing practices, in making decisions, etc, this is the theory around which we organise our thinking. The fourth component, the therapy, consists of the continuous education of the ego of the disturbed child or adolescent, who has still a flexible ego.
Those in need of residential treatment have severe ego deficits, either undeveloped or maldeveloped ego structures. Our primary tasks, therefore, are to support and facilitate ego growth. This we endeavour to do initially by placing our students in an entirely new environment where they can form new attachments and new identifications. The dramatic tactic of having them not see their families for a year ensures that they will direct their energies, both constructive and destructive, towards the people in their immediate environment so that they can develop new modes of coping. Available to them are repeated experiences for satisfying their needs and mastering the tasks of life. At the same time we present them with carefully graded expectations so that they may experience a sense of continuous growth. Since the ego develops in the exercise of its functions, providing opportunity for successful ego functioning consistently by day and night should encourage its maturation.
The way we provide structure and support is informed by our understanding of the theory of psychoanalytic ego psychology. For example, in order to know what experiences are appropriate (the kinds of games to play, books to read, etc) we have to understand each student’s level of ego development, his/her needs and motivations, and anxieties. From this knowledge we can generate experiences that the student can master and are of an interest to produce just enough anxiety to attract but not enough to overwhelm.
This perspective also applies to the staff. Insights gained from the knowledge of the unconscious facilitate staff empathy with the chaotic inner lives of their students and enable them to manage the emotions that are stirred up by this work.
Though our emphasis is on growth of the ego through the development of new identifications and ways of relating, we also have to deal with inner conflicts and transference-like relationships. Techniques for dealing with these issues are also derived from understanding psychoanalytic theories.
The desirability of a milieu providing constant ego supportive structure for youngsters with severe ego deficits is difficult to deny. Two problems encountered in the formation of such an environment are the understanding of what comprise the conditions for ego maturation for each individual, and the education of personnel to a level of sophistication so that they can consistently provide this.
We regularly discuss among ourselves and with our consultants the dynamics of each student so that we can arrive at an understanding of what particular conditions are desirable for each person.
The counsellors and teachers make up the most significant part of the human milieu. It is, therefore, essential that they be educated and supported to create the conditions both in general and in particular to facilitate ego growth. The counsellors are, usually, recent college graduates. They are bright, sensitive and committed to the helping professions. They learn through doing, guided and supported by daily staff meetings with the Directors and our two consultants, by frequent discussions with senior staff and their co-workers, and by frequent interactions with the directors and other senior staff in the actual milieu setting.
The following incident exemplifies several issues in milieu treatment. An 11 year old boy came running down in tears to complain to the Director about something that had happened – another boy had teased him. He said that he had had a terrible day in school. He interrupted a teachers’ meeting in his distress. After some sympathy had settled him down temporarily, the Director rejoined the meeting. His teacher said, “He didn’t have a terrible day, he had a very good day.” This was a breakdown in empathy, which the teacher could fairly quickly understand. (That is, he saw it as a bad day, she saw it as a good day.) She then could explore why it had seemed important for her to state that he had had a good day. It turned out that she had to see it that way for her own feelings of well being. The boy had, in fact, had a day that was predominantly full of achievement, but ended with an upsetting mishap. If she, like he, were to believe that this mishap ruined the day, it would have been a blow to her self-esteem and hard work. So while he blotted out all of the good, she blotted out all of the bad. Of course, it would be beneficial for him to remember the good, but he could not do it before his misery was understood and accepted. In order to be ego supportive, the staff has to be able to see the world through the patient’s eyes, yet not be so devastated by that vision as to lose sight of true achievement or as to lose their own self-esteem.
A critical issue in our approach is the importance of the milieu staff, the people who are with the students the most. With this in mind in reviewing our work, the question arises as to how it is possible with relatively untrained staff to effect such critical changes. In order to clarify some of the means by which we can do this and some of the problems involved in trying to do so, I have used as case vignettes only those which describe the course of treatment over a period of time when the student was not having individual sessions and when the staff working with the student was relativly inexperienced. In our efforts to educate the egos of these children critical issues have been: to provide nurturance, non-retaliative response, and attitude that all actions are meaningful, and consistency. For some of these, the issues themselves are fairly easy to understand and on some levels at some times to effect. For some, it is difficult to effect without more sophisticated understanding. For example, it is possible to believe that all actions make sense under ordinary circumstances. However, it is difficult to maintain that attitude when presented with bizarre or contradictory behaviour. It is the unusual staff member who, without being educated, can believe that the girl who is saying, “He hit me”, when no such thing has happened, is understandable. It is also difficult to have reasonable expectations without an understanding of the student’s dynamics. It is difficult for some to provide basic, primitive care to someone who seems quite capable of doing it himself; and it is difficult not to feel retaliative to a hostile attack.
At times, some of what is necessary for the ego education can be provided by the staff members following general practices that are fairly easily learned as they are demonstrated by other staff members and talked about at staff meetings. In each instance, however, there are times when particular guidance or support is needed because carrying out the practice is very difficult.
In this respect the initial example of Kate is pertinent. She would stubbornly refuse nurturance. Often the Director had to buttress the staff’s action when their efforts were not adequate to overcome her resistance. She served as chief judge for deciding exactly how much Kate had to eat. It was the Director’s decision that she should be held, as it was her decision that she should be forced to eat more than a maintenance diet. In order to be able to effect these decisions, the staff had both to understand and agree with them. Though the staff had been instructed that she should eat adequately, and had discussed it a great deal, it was not until the Director was actively involved in the details, and everyone could see that it was consistently after Kate not being made to eat that she became radically upset, that they could really effect it.
At the Orthogenic School these kinds of interactions take place by means first of having the Director and Associate involved intermittently in the daily life of the student, and by all staff regularly discussing the student in meetings both with and without a consultant.
Dora, who came to us at thirteen, presented another set of problems. Just prior to coming to us, she had refused to leave home, insisted on sleeping in the same room as her father, would not eat with the family, would eat only soft foods, was phobic about snakes, fire and choking, and described an hallucination of a dog in a tree.
She wanted very much to enter the Orthogenic School. However, two days after admission she became mute. Nevertheless, she wrote in her notebooks about: the dog in the tree; choking; suicide; John Lennon’s death; and snakes eating dogs. She would not lie down at night unless a staff member was in the room. When the staff continued to offer her care and concern, but stopped staying with her at night, she would go out in the hall. She was repeatedly brought back into her dormitory and bed by any staff member who happened to walk by. She gradually stopped doing this and would go to bed.
She would put signs up, “counsellors keep out” and would do other things that were of a rejecting nature, but seemed at the same time to call attention to her. After three months she suddenly started talking to everyone but the Directors. She then said that the silence and dog in the tree stuff was all an act to get to the Orthogenic School. She claimed that the psychiatrist who had interviewed her for the school district had advised her to act really crazy so that the school system would pay for her going to the Orthogenic School. We did not contradict her and for the next year she acted the model child – doing all the things that a good Orthogenic School student would do, except to discuss any kind of feelings. She would say that she was the only kid at the Orthogenic School who wasn’t crazy – she was only here because she did not want to live with her parents. She continued to be surrounded, however, by youngsters who did express their feelings and whose feelings were accepted. She was never pressed to do so herself. Our consultant agreed that she could maintain her “sane” presentation in the protected, nurturing environment of the school and that it would be ill advised to press for any greater expression of feelings until she was stronger. She began after a year to be more self-assertive, expressive and asked to have sessions.
With Dora it seemed that the safe, nurturing, accepting non-retaliative, understanding environment was enough to give her safety to grow. The staff needed support, in fact, not to carry out too strongly some of our practices. They needed support to leave the dormitory without guilt before she was asleep, and not to probe or particularly encourage her to talk about her feelings. Again, change could be effected by carrying out basic milieu therapeutic practices.
To summarise: milieu therapy at the Orthogenic School consists of: a physical environment, a human environment, a theory and a therapy. The physical environment is the school that is physically attractive, safe and warm; the human environment are the people that I have enumerated and, in part, described; the theory that informs our action in and arrangement of these environments is that of psycho-analytic ego psychology, modernised with some more recent psycho-analytic concepts introduced by our consultants and by members of our staff who are involved in various forms of continuing education. The therapy is the gradual and consistent education of the ego. This involves the modification of, on the one hand, the external environment and on the other the internal environment to suit the capacity of the weak and/or malformed ego. It involves, at the same time, the provision of ego support to help the student develop the various ego functions: perceptions, impulse control, integration, etc.
I have presented this therapy through example and description. Through case vignettes I have focussed on the problem of how to create a human environment that is able to provide a consistency of conditions for ego growth, conditions that are apparently simple but actually very difficult to effect when confronted with the demands of severely disturbed individuals.
In doing so, I hope to have stimulated the reader’s thinking so that reflections on our practices and problems will facilitate re-evaluation and refinement that can lead to bright prospects for the future efforts of all of us to understand the treatment needs of those who turn to us for help.
In order to give some idea of the kind of students we treat and the result of our treatment, I include the following data which is based on “man in the street” type of follow-up information rather than any systematic survey.
From July 1, 1972 to July 1, 1982, 59 students left the Orthogenic School. Most of these separations were what we call “graduations” – replete with individual ceremony honouring a job well done.
The population sample were 32 males and 27 females. Their ages at intake ranged from 6 – 20, at leaving from 12 to 28. The mean age at admission was 12. The range in IQ was from untestable to 150. The referring diagnoses include childhood schizophrenia, childhood psychosis, character disorder, autism, and borderline and passive aggressive personalities. In terms of DSM II our sample would contain the full variety of childhood disorders – though I would not be satisfied that only one of the diagnostic labels would be adequate for any of our students.
They all suffer from major emotional disturbances including severe ego deficits as well as inability to manage in any of the three major spheres of childhood and adolescent involvements: school, family and friends. Our requirement that the student not see his/her parents for one year reflects the severity of the disturbances. Parents are not likely to agree to this condition unless they are desperate.
Individuals in our sample range from being patently bizarre with very little evidence of normal strengths through the seemingly normal with the disturbances not immediately apparent especially in a benign, structured setting. The bizarre vary from the extreme autistic withdrawal in some of the younger with their self-stimulating and idiosyncratic movements to the more organised magic rituals of some of the older students. Those students who appear normal are frequently impossible to live with because of their poor impulse control, manifest anxiety and their inability to process messages accurately. Our preference for admission to the school determines our sample. However, we maintain a balance so that bizarreness and disorganisation do not predominate. Since our milieu is designed to present an atmosphere of health, the bizarre should not exceed the striving healthy.
An informal survey of the 59 students who had been separated from the school from 1 to 11 years was made in 1982. Twenty-nine were successfully mastering or had successfully mastered college experience; that is, 9 were in college, 10 had graduated and were successfully directed (eg, starting graduate school) and 10 had graduated and attained yet another significant level of achievement (eg, job, graduate school, marriage). Nine were married, though one was divorcing. Three others had achieved job success without college. So, of the 59 these 32 were engaged in age-appropriate activities in society and involved in the tasks of the world.
Eleven of the 59 were conditionally achieving these levels of functioning, but the outcomes were not yet certain: that is, 2 had achieved some success in work or college, but were dependent on their families; 4 had achieved similar success but showed evidence of inappropriate social behaviours and had not yet been able to consolidate their therapeutic gains; and 5 had variable achievements and impulse disorders coupled with dependence.
Another 5 of the 59 were living at home within a supportive programme; these will not be able to function independently.
Two are now living in sheltered care facilities and are likely to continue to do so. They are likely to be able to have a fair degree of self-care and a benign fairly enjoyable existence.
Six are institutionalised with prospects for lifetime severe illness.
Two were transferred to other therapeutic facilities with prospects for possible improvement with a somewhat different mode of treatment.
B. Bettleheim (1965) Love is not enough. New York: Collier Books.
B. Bettleheim (1974) Home for the Heart. London: Thames & Hudson.