Which intervention demonstrates responsibility for the milieu in an inpatient psychiatric setting

Environmental Interventions

Asthma guidelines recommend reducing exposure to relevant allergens and irritants to reduce inflammation, symptoms, and need for medication. Environmental control represents a financial and practical burden for both patients and society. Successful approaches need to set realistic goals that account for limitations imposed by the inner city setting. Necessary resources may not be available for optimal environmental control. For example, only 38% of homes in NCICAS had functioning vacuum cleaners.98 Current approaches include integrated pest management, which consists of filling cracks with copper mesh, vacuuming, putting away or disposing of food, rodent traps, and application of low-toxicity pesticides to control cockroach and mice infestation, fitting impervious mattress and pillow encasings, or running an air filter.99,100

Krieger and associates101 used community health workers to provide in-home environmental assessments, education, support for behavior change, and resources. The intervention reduced asthma symptom days and urgent health services use while improving caregiver quality-of-life score.

The ICAS implemented a multifaceted home-based environmental intervention for inner city children with asthma. Intervention was tailored to each patient’s sensitization and environmental risk profile, using a series of modules to reduce home allergen exposure.102 In this randomized trial, the individualized intervention reduced exposures to cockroach, mouse, and dust mite allergens and resulted in significantly fewer symptom days during the intervention year and during the year after intervention.71,103 A multifaceted allergen avoidance study by Carter and colleagues104 studied the effect of avoidance of dust and cockroach in a group of inner city children with asthma. Although there was no overall improvement in the intervention group compared with the control group, significant reduction in acute visits for asthma was demonstrated for mite-allergic children who had a significant decrease in exposure to mite allergen. DiMango and colleagues105 demonstrated that environmental control measures in allergen-exposed and sensitized individuals effectively reduced levels of all measured household allergens (i.e., roach, mouse, dust mite, cat, and dog), but did not lead to stepping down asthma controller therapy compared with a control group receiving a home visit that did not target allergies and asthma. The Mouse Allergen and Asthma Intervention Trial (MAAIT) compared professional integrated pest management and education to education alone in inner city children exposed and sensitized to mouse.106 The trial found no significant difference in symptom days between the intervention and control groups. However, in both the DiMango and MAAIT trials, participants in control and intervention groups had reduction in allergen exposures and symptoms that could have resulted in an underestimation of the benefits of the interventions. Of note, across both intervention and control groups, both studies showed a dose-response relationship between mouse allergen reduction and asthma control.

V. Case Illustration

Consider Jeremy a 13-year-old Caucasian male receiving services in a large-scale residential facility. In addition to full participation in the milieu therapy provided to all residents, Jeremy was also referred for individual psychological services due to social skills problems, oppositionality, and ongoing severe conduct problems. His behavior problems significantly affected his social functioning in that he was severely rejected by his peers. Teacher, peer, and other staff report all indicated that Jeremy was actively avoided, taunted, and made fun of by the majority of his peers. For example, it was not uncommon for Jeremy's peers to say something such as “Don't talk to me!” in response to his attempts to initiate interactions.

Further assessment on initiation of psychological services revealed the presence of significant social skills deficits that likely contributed to his social rejection. First, he was awkward in his attempts to initiate or maintain conversations. Specifically, he would attempt to start conversations by yelling hello to peers or adults from across the room and generally speak with a voice that was louder than conversational level. Second, Jeremy would attempt to procure interactions with popular peers by using age-appropriate phrases or wearing “trendy” clothes. Rather than elevating his social status, these attempts appeared to further alienate him from his peers, as evidenced by laughter and jeers directed toward him. Third, Jeremy tended to use mannerisms and gestures that were exaggerated and excessive. Fourth, Jeremy demonstrated poor table manners, as evidenced by him talking with food in his mouth, eating rapidly and/or with his finger, and eating in a messy manner (resulting in food being on his face and/or clothes). This particular behavior pattern often set the stage for ridicule and rejection during the lunch recess hour. Finally, Jeremy typically presented with a facial expression characterized by a clownlike vacant grin.

Modeling procedures were used during individual therapy sessions to target his social skills deficits directly. First, in vivo modeling was used to target his poor table manners. To accomplish this, the therapist conducted 3 one-half-hour sessions weekly while he and Jeremy sat together at a dining table in the lunchroom at Jeremy's junior high school. Sessions occurred during Jeremy's regular lunch period while he and his peers ate lunch. After establishing the need to target table manners, and describing the rationale for participant modeling, the therapist described verbally and demonstrated physically proper table manners (e.g., use of a napkin, appropriate rate of eating, chewing with one's mouth closed). Then, collaboratively the therapist and Jeremy selected a specific skill for focus, rather than attempting to intervene with all relevant behaviors at once.

Once the target skill was selected, the therapist initiated each session by verbally and physically reviewing the proper target behavior and then drawing Jeremy's attention to peers who were demonstrating that behavior while they ate lunch. During the observation, the therapist would verbally describe the behavior being modeled by the peer, as well as point out the positive social benefits of engaging in such behavior. After a brief period of observation, Jeremy was then instructed to eat his lunch while attempting to demonstrate the appropriate response. Positive and corrective feedback was provided during this time. Periodic prompts to observe his peers were also provided until Jeremy demonstrated the skill successfully.

In conjunction with in vivo modeling to target table manners, symbolic modeling was used to address various other social skills problems (e.g., facial expressions, voice volume). Sessions involving symbolic modeling typically occurred every other week in a therapy session room. Again, the deficit skills were identified and reviewed prior to implementing the intervention. Furthermore, appropriate skills were also discussed and modeled by the therapist. Examples of targets identified included taking turns appropriately, offering praise to his peer, and displaying facial expressions appropriate to the context. After establishing the target behaviors, symbolic modeling was implemented. Symbolic modeling in this case took the form of videotaped interactions between Jeremy, the therapist, and another similar-aged male peer. The peer was selected because care providers had identified him as being quite socially skilled. Interactions occurred in the context of involvement in some sort of board game. Following 10–15 min of playing the game while being videotaped, Jeremy and the therapist would review the videotape so that Jeremy could observe the peer implement appropriate social skills. Further, Jeremy's behaviors were evaluated, and positive and corrective feedback was provided. Then, Jeremy was provided with another opportunity to interact with the peer and the therapist while playing a game, thus allowing for imitation of the desired responses.

Modeling procedures were effective in altering some of Jeremy's serious social skills deficits in the therapeutic contexts. He learned how to eat in a more socially acceptable manner while the therapist was present, how to talk in a more normal tone of voice while playing a game with a peer, and how to change his facial expressions to more closely match the situation (e.g., smile when there was a joke told, scowl when losing the game). The level of prompting that was needed to ensure the use of these skills decreased during the therapy situation. Unfortunately, however, Jeremy was discharged from the residential program before specific measures could be taken to prompt generalization and maintenance of treatment gains, as these did not appear to be occurring naturally.

Environmental and behavioural interventions

There is a growing body of evidence that environmental, behavioural and non-pharmacological strategies can reduce the behavioural and physiological indicators of pain and stress in the newborn. These principles are encompassed in the concept of developmental care which leads to improved neurobehavioural organisation, lower morbidity and earlier discharge (Als et al. 1986, 1994). Minimising painful procedures to those absolutely necessary and clustering them together can reduce the frequency of noxious stimuli. Other techniques thought to be beneficial include decreasing handling, reducing ambient noise and light, and establishing day–night cycles (Franck and Lawhon 1998).

Behavioural strategies useful in reducing pain scores during painful procedures include gentle sensory stimulation of the visual, tactile (Gray et al. 2000), auditory (Locsin 1981) and taste senses. Oral sucrose and sweet compounds are safe and effective at reducing pain scores during invasive procedures. There is a dose-dependent effect from 5% to 50% but the optimal dose is not known (Stevens and Ohlsson 2000).Bellieni et al. (2001) combined oral 10% glucose, non-nutritive sucking and multisensorial stimulation into a process of ‘sensorial saturation’. They found that this was more effective at reducing pain scores than any of these techniques alone (Bellieni et al. 2001). A Cochrane review has recommended oral sucrose as analgesia for procedural pain in newborns, based on its effect in reducing pain scores (Stevens et al. 2010), but a recent randomised controlled trial has demonstrated that, while reducing the PIPP score, oral sucrose does not reduce the cortical response (Slater et al. 2010b). Proprioceptive, vestibular and thermal stimulation occurs through swaddling, rocking and maintaining a flexed position (facilitated tucking) (Franck and Lawhon 1998). The use of melatonin is still in the research domain but it may prove useful to regulate the circadian rhythm (Seron-Ferre et al .2001). An overview of general strategy is shown inTable 25.4.

IV. Effectiveness of the Token Economy

Maconochie's anecdotal reports indicate that the recidivism rate for inmates released from his program on Norfolk Island was markedly lower than that for other prisons in the British colonies. More recent empirical research provides general confirmation of the effectiveness of properly designed and implemented token economies. Perhaps the most influential of the empirical studies is Paul and Lentz's thorough-going experimental comparison of milieu therapy and social learning therapy with a severely disturbed psychiatric population in a large state hospital. They defined the milieu approach as consisting of increased social interaction and group activities, expectancies and group pressure directed toward normal functioning, more informal patient status, goal-directed communication, freedom of movement, and treatment of patients as responsible people rather than custodial cases. The social learning approach was described as the systematic extension of principles and techniques derived from basic research on learning to clinical problems, specification of specific behaviors for change, emphasis on response-contingent consequences, and the use of token economy programs.

In general, Paul and Lentz found the token economy to be superior to the milieu program in terms of both in-hospital improvement and then postrelease adjustment during a year and a half follow-up period. It was also found to be the more cost effective of the two approaches. The milieu approach, in turn, was found to be superior to routine hospital care for both the in-hospital and postrelease indices of program effectiveness. Findings such as these ensured that the token economy would become an important component of many treatment programs for persons with mental illness as well as in educational settings, training schools, and prisons.

Environmental Intervention

Although resources and space may be limited, the environmental intervention is of critical importance for a patient in crisis. The environment will determine if the patient will sit, stand, or lie on a stretcher; if he or she will wear street clothes or a hospital gown; and if the clinician will be alone with the patient or be accompanied by family or other emergency staff. If possible, the interview should occur in a quiet, clean setting, where the patient and the clinician can both sit comfortably and not be overheard by strangers in the ED. This, of course, depends on the patient's behavior; the presence of other staff or security in the ED is paramount for safety when working with a patient who appears agitated or impulsive. Attention to the patient's basic needs (e.g., offering a blanket in a cold room, being sure that the patient has access to a restroom, and offering the patient something to drink or eat) will assist in forming an alliance.

WORKING IN AN INTERDISCIPLINARY SETTING

Interdisciplinary treatment is the norm in inpatient settings. Communication among treatment providers from different disciplines is useful in practicing ACT in an interdisciplinary setting, where incorporating ACT principles and interventions into other treatment modes will likely be necessary. In inpatient settings therapy may consist of only a few sessions, given that average hospital stays are brief. However, many ACT concepts can be introduced and/or reinforced in multiple treatment modalities; for example, identifying goals and values and opportunities to practice skills, addressing barriers to participation in other treatment components, and monitoring progress. Milieu therapy may be the primary setting in which the client has opportunities to practice defusing from thoughts and feelings. Communicating with other staff and educating them about ACT conventions, such as saying, “I'm having the thought that …” or asking a client, “Are you going to buy that thought?” can reinforce what is learned in therapy sessions if ACT concepts are repeated by other staff.

In inpatient (or outpatient) psychosocial rehabilitation programs ACT can be effectively done in a group therapy setting with persons with serious mental illness. Group meeting time should be kept relatively brief, around 45 minutes. Alternately, ACT principles and exercises can be incorporated into existing groups. For example, it can be effective to introduce cognitive defusion, acceptance, and mindfulness practices into a symptom management group, or willingness and values into medication management and goal setting groups.

Finally, other treatment providers may believe that the client's symptoms should completely remit before they are discharged from the hospital. Many clients have learned that denying symptoms means that they are more likely to be discharged, while acknowledging symptoms means they are more likely to remain hospitalized. If longer hospitalization seems indicated, the therapist can work with the client on goals and values other than discharge and explore how remaining in the hospital might increase opportunities to learn more skills and put the client in a better position to attain valued goals. Alternately, if discharge is indicated in spite of ongoing symptoms, the therapist might act as an advocate on the treatment team and point out positive changes in the client's behavior in spite of ongoing symptoms, and if applicable, educate staff about ACT.

Psychotropic Drugs

The use of these drugs is described in detail in Chapter 90. In using these drugs, physicians must follow the same principles of evidence-based treatment as they would with patients who do not have ID. They should be used in a lowest effective dose and follow-up data should prove their effectiveness. A “Christmas tree” treatment model should be avoided (adding one drug after another if the previous one is not effective, rather than discontinuing the ineffective one), unless a combination is clearly proved to be effective. These drugs should be prescribed (as any other drug is) by a physician who is thoroughly familiar with them. They should be a part of a comprehensive treatment program, not a substitute for it. Various treatment modalities, such as psychotherapy, milieu therapy, and behavior modification, have a synergistic effect with the medications. As much as possible, these drugs should be used for their designated action in specific disorders. For example, antipsychotics should be used primarily for treatment of psychotic disorder and not as a nonspecific “major tranquilizer.” Whereas they are often prescribed “for aggression,” there is really no specific anti-aggression drug. Aggressive behavior may be caused by psychosis, depression, a painful condition, anger, or reaction to environmental conditions, each of which requires quite different interventions. High doses of an antipsychotic drug might suppress any aggressive behavior but at the cost of side effects and suppression of the person's general functioning.

Another caveat in the use of drugs in this population concerns side effects (American Academy of Child and Adolescent Psychiatry, 1999). Children and adolescents who do not have verbal skills may have considerable difficulty in reporting side effects. They should be monitored carefully, according to predetermined criteria and baseline data. Some side effects may mimic original symptoms; for example, akathisia resulting from a too rapid withdrawal of an antipsychotic, particularly a first-generation one, may look like an increase in preexisting agitation, especially if the patient cannot describe how he or she feels. The involuntary movements of tardive dyskinesia may be difficult to differentiate from preexisting stereotypies. Videotaping of the patient's behavior before the drug is started may help in this differentiation.

A useful summary of precautions necessary with the use of psychotropic medications in persons who have ID has been issued by the Health Care Financing Administration (reviewed in American Academy of Child and Adolescent Psychiatry, 1999). Other useful resources are Reiss and Aman (1998), Rush and Frances (2000), and Harris (2006).

Psychotropic drugs are further discussed in Chapter 90, milieu therapy in Chapter 89, and behavior modification in Chapter 87.

Comparison and Contrast with Today’s Hospitals

In some ways, the 19th-century state hospital bears little resemblance to today’s hospitals. The locations are often similar, usually remote settings and often self-sustaining communities. Many had large working farms, produced crops, and raised livestock. Most of the support services needed—hardware, blacksmiths, and central heating or power plants—were on the grounds. Some had their own factories. Until the 1950s, everyone associated with such a hospital—staff, nurses, and doctors—lived on the grounds near the patients.

At the peak of what was known as the “moral treatment era,” the precursors of two intervention strategies that later became prominent in PsyR were initiated in these hospitals. While the exact phrases were not employed, early attempts at milieu therapy and the work-ordered day (discussed in Chapter 6) were pioneered at these institutions. There was a strong belief, for example, that (as in milieu therapy) the environment was the treatment. In addition (when feasible), the work-ordered day, later utilized by the clubhouse movement (see Chapter 7), was seen as beneficial for persons who had uncontrolled psychotic symptoms.

Many hospitals were based on the model developed by Thomas Kirkbride (1809-1883) described by Osborn (2009) in On the Construction, Organization, and General Arrangements of Hospitals for the Insane, which outlined the components of an asylum. Ideally, a hospital was built on the outskirts of a moderately sized town, accessible by railroad, and with land for farming and gardens. These institutions literally maintained themselves with the goods, services, and products they required to have a functioning community (Rothman, 2002). They were their own worlds, or at least their own separate communities. The hospitals would have symmetrical wings coming off a central administrative building with at least eight wards per wing. The wings were designed for good ventilation and lighting. Large windows and solariums were provided, especially in areas where patients spent their days. However, there were bars on the windows to prevent patients from escaping. The symptomatic and violent people lived in the wards farthest from the central administrative building, the “back wards” (a phrase still in use today) so as not to upset calmer patients. Thomas Kirkbride, who served as a hospital superintendent, instituted therapeutic beauty, including gardens, fountains, trails, and a grandiose architecture. He thought the hospital should look as attractive and impressive as possible to reassure and calm the patients, while bolstering support of family members who committed their loved ones. Kirkbride believed that architecture and landscape could help cure insanity. He also paid a great deal of attention to security, ensuring the durability of the hospital to withstand wear and tear by the patients.

He founded his masterpiece, Greystone Park Psychiatric Hospital, Morris Plains, NJ, in 1876. At its peak, the campus covered a square mile. Its 43 buildings once housed more than 6000 patients as well as about the same number of staff. The buildings themselves offer a remarkable record of 19th- and 20th-century institutional and residential architecture. From 1876 to 1943, the main administration and treatment building, the Kirkbride Building, was the largest structure on a single foundation in the United States (Preservation New Jersey, 2003). In its history, the hospital saw the introduction of a number of positive developments, including occupational therapy, antipsychotic medication, and the use of small cottage residences organized around PsyR principles. However, other earlier treatment approaches actually proved to be harmful to many patients, such as psychosurgery, the long-discredited severing of nerve fibers in the brain’s frontal lobes referred to as lobotomy.

Greystone has been consolidated mostly into a new single building finished in 2008 that, from its exterior, bears a resemblance to a prison. It now has fewer than 600 patients at any given time, half of whom are awaiting placement in the community. The hospital had been scheduled for a downsizing by a further 250 beds, accompanied by a significant expansion in community services.

State hospitals have other continuing legacies besides their architecture and physical plant. In some places, large dormitory-style housing without privacy for the patients still exists. Other elements of the legacy include separation from the rest of the world, including both a physical and psychological distance from most communities. In many hospital settings, there is another vestige from an earlier time: the belief that recovery of any sort from a serious mental illness is not a likely outcome (Birkmann, Sperduto, Smith, & Gill, 2006; Dhillon & Dollieslager, 2000).

One of the greatest barriers to implementing PsyR in hospitals may be an attitudinal one, embedded in the culture and practices of the institutions (Dhillon & Dollieslager, 2000; Birkmann et al., 2006). Many staff members in these institutions simply do not believe that persons with severe and persistent mental illness can actually recover to any meaningful extent. In part, this may be a consequence of the fact that hospital staff sees patients in the acute phase of their illness (Cohen & Cohen, 1984) rather than when they are not symptomatic, coping well in the community, and living independently. This is a version of what Harding and Zahniser (1994) refer to as the “clinician’s mistake based on experience”. Cohen and Cohen (1984) refer to it as the “clinician’s illusion”. Hospital staffs literally see people at their worst in the acute stages of their illness. They rarely see patients at their best. As a result, their conception of persons with these disorders is based on their experiences of the patients as they are in the hospital rather than on how they function in the community.

The economic crisis that began in 2008 spurred an increased number of US state psychiatric hospital closures. Despite significant growth in population, there has been a long-term trend in decreasing state psychiatric hospital censuses since the 1950s (Geller, 2000). Recently (2008-2012), the trend has reaccelerated because states, starved of their usual level of tax revenues, have been cutting their expenditures. State hospitals remain expensive; closing them appears to save a lot of dollars, at least in the short-term. Still, if recidivism or the number of persons with unmanageable illness increases, this trend may reverse itself.

In many places, public hospital closures have resulted in reinvestment of funds for community services. In some US states, Italy, and other countries, legislation provides that resources saved by the closing of public hospitals must be reinvested in community-based mental health programs, including PsyR services such as assertive community treatment, co-occurring disorders programs, supported housing, and supported employment. It makes sense that to live in the community, people who were formerly hospitalized need enhanced services. Hospital utilization (i.e., number of hospital days) by these individuals can be greatly reduced by such services. Sadly, with today’s economic downturn, the closure of hospitals is resulting in the reinvestment of only 25 percent or less of their operating expenses for community-based services.

Kuhn's Construct of Paradigm: Application to Occupational Therapy

Although Kuhn developed the paradigmatic model to explain development of knowledge in the basic sciences, it can be applied to practice disciplines such as occupational therapy to explain evolving discipline's core constructs, focus, and values.33 Kielhofner and Burke34 used the model to explain occupational therapy's changing identity since the moral treatment era. According to Kielhofner,33 the formal founding of occupational therapy as a profession was preceded by a pre-paradigm (the moral treatment movement). During this era, the idea that mental illness was caused by environmental factors emerged. It was argued that effective treatment of the mentally ill was environmental modification. Furthermore, society had an obligation to help the mentally ill return into the mainstream of life.

Central to this form of milieu therapy was the therapeutic use of daily occupations including self-care, education, physical exercises, and recreation designed to “interrupt the chain of morbid thoughts,” direct “the attention on more pleasant subjects,” and “maintain order” (p. 20)46 among clients. Also, therapy was based on the premise that the mentally ill retained a certain measure of rationality. This residual intellectual capacity could be appealed by use of intellectually challenging occupations, resulting in a return to rationality through the individual patient's actions.55 Thus the responsibility of healing was on the patient, and the therapist was a facilitator. Although Kielhofner does not state it, it may be argued that the arts and crafts movement was also part of the pre-paradigm. As discussed in Chapter 1, this movement introduced the idea that alienation in the industrial society caused mental illness, and engagement in arts and crafts helped decrease this sense of alienation, leading to better mental health.46 Thus arts and crafts became a media of therapy and would remain so after occupational therapy was founded, perhaps even until the 1970s.

At the turn of the twentieth century, a variety of ideas from the moral treatment movement and the arts and crafts movement coalesced into the formal founding of the profession of occupational therapy. Principles of the new profession were articulated, constituting the first paradigm for the profession—the paradigm of occupation. In this paradigm, the founders of the profession saw their task as convincing the public “of the important relationship between creative work and health” (p. 32).46 However, beginning in the era of the Great Depression, and exacerbated by the rise of the rehabilitation movement, an anomaly arose in which the medical profession challenged occupational therapists to explain what they were doing scientifically. This anomaly/challenge led to a loss of confidence in the ability of the paradigm of occupation to offer scientific justification of the existence of the profession.13,33 Occupational therapists responded to this crisis by revising the paradigm and adopting the reductionistic, mechanistic medical model. Normal practice within this paradigm included a focus on the internal intrapsychic, kinesiological, and neurological systems in therapeutic interventions.

Very soon, however, the reductionistic medical model proved inadequate as a guide for occupational therapy. The profession began to look more and more like physical therapy with predominant use of exercises as therapeutic media or like social work with extensive use of talk therapy.19,31 Thus there was role blurring.18 Furthermore, this paradigm did not address the problems of chronically ill patients. Also, it was inadequate in helping therapists address the full spectrum of occupational problems of humans as they interacted with the environment.33 This led to a loss of confidence in the paradigm and the rise of another crisis. The response to this crisis was a call to return to the roots of occupational therapy in the moral treatment movement and the principles articulated by the founders of the profession at the turn of the twentieth century (see Chapter 2). This call led to concerted activity among scholars in the professional community, leading to articulation of a new paradigm in the early twenty-first century. Since the paradigm is client-centered,1,33 we will refer to recipients of occupational therapy services as clients and not patients.

1.3.1 1950–65

When the second half of the twentieth century began, psychoanalytic perspectives dominated the mental health field. Many of these perspectives were constructive developments correcting old Freudian theory or extending psychoanalytic theory into areas uncharted by Freud (cf. Winnicott 1958). For example, Freud's daughter, Anna, did much to develop the method of treating children through analyzing their play. Erik Erikson extended psychoanalytic theory into the study of culture—and simultaneously gave us today's umbrella term, identity, for explaining adolescence. Margaret Mahler and Donald Winnicott corrected Freud's overemphasis of the Oedipal complex by demonstrating the centrality of object relations in the process of an infant and young child's ‘individuating.’ And Bruno Bettelheim, Fritz Redl and others extended psychoanalysis into the design of residential treatment. In a discussion of mental health programs, this last development requires some explaining.

Bettleheim, Redl, and others called their work ‘milieu’ therapy. By this they meant the shaping of virtually everything that went on in residential treatment to support a child's ‘ego’—from picking out furniture that would withstand the not-so-occasional abuse of the troubled child to using a child's tantrums to promote insight through ‘life space’ interviewing. The milieu of these residential treatment centers worked, then, o help children and adolescents develop their own ‘inner controls.’ The writings of Redl and Wineman (1965) in particular provide fresh insights into what it takes to support troubled children and their development. Sadly, much of this extraordinary history in mental health programing is forgotten today—another example of how younger practitioners with new ‘medicines’ may fare no better than older practitioners who knew how to use older ‘medicines’ in extraordinary ways.

Psychoanalytic theory in the 1950s and early 60s also helped to spawn a number of offshoots that defined themselves as reactions to features in psychoanalytic theory and practice. Humanistic psychology and Virginia Axline's play therapy provide one example. Attachment theory and John Bowlby's work on the ‘secure base’ phenomenon provide another. During this period, Axline's play therapy had a widespread influence on how psychotherapy for children was conducted, but it was Bowlby's (1973) work on the dangers of separating child from caregiver that influenced changes in mental health programing. Bowlby's work and Renee Spitz's (1945) previous work on institutionalized children provided conceptual fuel for the later trend toward family preservation and keeping even pathogenic families together.11:44 AM 2/5/2004

However, during this first period, psychoanalytic perspectives and their offshoots were not alone. This was the period when Piaget, Vygotsky, and, to a lesser extent, Werner became widely read—ushering in the so-called cognitive revolution. As mentioned earlier, these cognitive perspectives on children did not at first have much impact on mental health programing, but, in subsequent periods, their influence has been increasing.

As mentioned before, behavioral theory developed into a clinical tool—to be used everywhere that clinicians could define dysfunction in terms of ‘target behaviors.’ From autism to anorexia, from infancy to adolescence, behaviorists worked to demonstrate that ‘All behavior is one.’ Most of these new behavioral therapies derived directly from the work on operant conditioning pioneered by B. F. Skinner. They differed from today's behavioral treatments and programs mainly in the limited and sporadic nature of their interventions.

Finally, with respect to relevant developments during this period, family systems theory and family therapy developed rapidly to become a major alternative to the traditional therapies which focused on pathology within the child (Barnes 1994). Family systems theory demonstrated that children's and adolescents' dysfunctional behavior often serves important functions within a larger system, usually that of the family. The leading figures, such as Jay Haley and Salvadore Minuchin, gave the movement an almost swashbuckling style as they poked fun at traditional perspectives and challenged family members with provocative prescriptions and ways of labeling their family roles. But today, family therapists often do their work as part of a mental health team—as happens in many hospital based crisis centers where children and adolescents come to be stabilized, assessed, and referred.