A THERAPEUTIC MILIEU*

BRUNO BETTELHEIM, PH.D., AND EMMY SYLVESTER, M.D.

The Orthogenic School, UniversiQ of Chicago

aper describes the treatment of emotionally disturbed children

TH
in an I S
institutional setting. The clinical material on which this discus-
sion is based concerns a syndrome developed in non-therapeutic institutions
which may be called “psychological institutionalism.” For the purpose of
showing how these children are rehabilitated a t the Orthogenic School, two
cases will be presented in full.
Psychological institutiona,lism may be regarded as a deficiency disease in
the emotional sense. Absence of meaningful continuous interpersonal rela-
tionships leads to improverishment of the personality. The results of this
process are observed in children who have lived in institutional settings for
prolonged periods of time, but it is not limited to them. I t also occurs in
children who are exposed to a succession of foster homes or to disorganized
family settings.
Non-institutional living per se will therefore not cure or avoid institu-
tionalism. Neither can psychotherapeutic measures be effective which neg-
lect the core of the disturbance. Only measures arising from benign inter-
personal relationships among adults and children can combat the impover-
ishment of the personalities of children who suffer from emotional institu-
tionalism. Since behavior disorders in the common sense do not necessarily
form part of the clinical picture, the factors which cause impoverish‘ment of
personality are only rarely subjected to psychiatric study. Understanding
these factors furnishes leads to the construction of a therapeutic milieu.
A frame of reference that consists of depersonalized rules and regulations
may lead the child to become an automaton in his passive adjustment to
the institution. There is no need for independent decisions because the
child’s physical existence is well protected and his activities arranged for
him. Compliance with stereotyped rules rather than assertive action consti-
tutes adequate adjustment, but does not allow for spontaneity. Reality
testing is not extended to variegated life conditions. Complete determination
by external rules prevents the development of inner controls. Emotional
conflicts cannot be utilized toward personality growth because they ale not
intrapsychic conflicts, but only occasionai clashes between instinctual tend-
encies and impersonal external rules. The cause of these serious deviations
in Personality development-the absence of interpersonal relationships-is
also responsible for their remaining unrecognized. The child lives in emo-
tional isolation and physical distance from the adult. Even in instances
where the child lives in proximity of touch and experience with adults, such
* Presented at the 1947 Annual Meeting.
191
192 A THERAPEUTIC MILIEU

closeness does not serve the purpose of personality growth if the significant
characteristics of the normal child-adult relationship are not maintained.
Frequent change in the personalities and absence of proper and consistent
dosage of the adult’s distance from and closeness to the child, turn into
shadowy acquaintance what should be intimate relationships. This “not
knowing” the adult deprives the child of images of integration.
In a therapeutic milieu, on the contrary, the child’s development toward
increasing mastery must be facilitated. Training in skills and achievemznts,
specialized programs and activities, are of peripheral importance onIy. They
are therapeutically justified solely if they originate from the central issue
of the therapeutic milieu. A therapeutic milieu is characterized by its inner
cohesiveness which alone permits the child to develop a consistent frame of
reference. This cohesiveness is experienced by the child as he becomes part
of a well defined hierarchy of meaningful interpersonal relationships. Em-
phasis on spontaneity and flexibility-not to be misconstrued as license or
chaos-makes questions of schedule or routine subservient to the relevance
of highly individualized and spontaneous interpersonal relationships. Such
conditions permit the emergence and development of the psychological
instances, the internalization of controls, and the eventual integration of
the child’s personality. I t may be assumed that these milieu factors which
determine the children’s rehabilitation in the therapeutic milieu, have valid-
ity for the institutional care of children in general.
The personality defects which result from the absence of these factors in
an institutional setting are clearly demonstrated by a control group of six
to eight year old children who were not considered disturbed b’y their en-
vironment. The reason for the psychiatric study was a “purely administra-
tive one”-they had reached the age limit of the residential institution in
which they had spent the greater part of their lives. They arrived a t the
clinic in groups and presented themselves as physically well developed, neat
and well-groomed youngsters. Their behavior in the waiting room was rather
striking: they seemed to have an unusual amount of group spirit and had
completely accepted their respective positions in the group as leaders, fol-
lowers, protectors, or proteges.
This apparent social maturity was in marked contrast to their behavior in
the individual contact with the psychiatrist, in whose office many were ex-
cessively shy whereas others became aggressively demanding. These forms
of behavior were fixed. Lack of the flexible adaptability which even disturbed
children show during the course of a psychiatric interview, characterized
these children. T h e shy ones remained shy throughout the interview. Others
were unable to modify their demands which appeared in two different and
mutually exclusive varieties. They took the form of “toy hunger” in the
children who had interest in toy material only, and of “touch hunger’’ in
 BETTELHEIM AND SYLVESTER 193

those whose need was exclusively for physical contact. The children who
were not overwhelmed by rigid shyness entered conversation readily, and
it was possible to get a picture of their subjective world.
In spite of psychometrically good intelligence, all conception of coherence
of time, space, and person was lacking. Their lives were oriented to washing,
dressing, eating, and resting, experienced as pleasurable and unpleasurable
purely in terms of their own bodies, and only loosely connected with the
adults responsible for their care. Hardly any of the children referred to the
staff by name. Some were able to distinguish individual staff members
according to the functions of physical routine they supervised. For many
children, there existed one exception in this nameless world: the nurse in
charge of the sickroom. This seems significant, since she was the only per-
son who, temporarily a t least, was in full charge of all the needs of the child.
The automaton-like rigidity of these children, their egocentric preoccu-
pation with functions of their own body, their inability to master a one-to-
one contact with an adult, are indications of a serious lag in personality
integration.
The deviation in personality development shown by these children allows
important conclusions. I t demonstrates the dangers of rearing in a setting
where a number of adults take care of isolated functions of the child rather
than of the whole child, and stresses the necessity of giving each child the
opportunity for a continuous central relationship to one adult in the insti-
tution.
Upon admission to the School, the children, whose personality develop-
ment in the therapeutic milieu will be presented, showed striking similarities
to this control group. While the severe psychopathology of the patients will
become obvious in the description of their gradual rehabilitation, it should
be kept in mind that none of the children in the control group were consid-
ered in any way abnormal by those who managed the institutional environ-
ment in which they lived.
The following case material demonstrates the slow and gradual emergence
of personality structure in two children who showed all the characteristics of
emotional institutionalism when they were admitted to the School. Here,
the simple activities such as eating, bathing, and going to bed, which had
also been provided in the non-therapeutic institution, are carried out within
meaningful interpersonal relationships. Thus they become essential thera-
peutic tools for personality rehabilitation.

Case 1:l A ten year old boy of superior intelligence had lived in various
institutions since his birth. His adjustment demanded psychiatric attention
Credit for most of the direct work in the rehabilitation of this boy is due to Miss Gayle Shulenberger
*nd Mrs. Marianne Wasson.
194 A THERAPEUTIC MILIEU

only when self-destructive tendencies of long standing culminated in a suicid-

al attempt. His life had been characterized by scarcity and tenuousness of
personal ties. During the process of rehabilitation, it became obvious that
his self-destructive act was more a desperate than a pathological effort to
break through his isolation. This he revealed in a situation which was char-
acteristic for him in the beginning of treatment at the School. An explosion
of rage had followed his awkward and ineffectual attempt to get close to
other children by provoking their aggression. It was then that he said, “I
went up on the Empire State Building and jumped off. After that everybody
was my friend.”
Although he had always lived in proximity to others, he had never ex-
perienced the structured hierarchy which differentiates children from adults
and thus permits their interaction. H e neither knew how to react to adults
nor how to get along with children. For him, adults were those who were
bigger than he, individuals who by virtue of greater strength and size en-
forced rules, inflicted punishment and prevented children from “bothering
them.”
One counselor devoted herself particularly to him. Though he was for a
long time unable to reciprocate the offered relationship, he immediately
utilized the additional comfort which the contacts with the counselor offered.
Toward the end of the first month, he expressed his first appreciation of her
devotion when he snuggled against her and said, “I am a laughing hyena.”
He could express happiness only by coloring his incorporative tendencies with
primitive feeling tones of joy. It took another month before he was able to
ask any personal questions of her, the person whom he knew best. Once,
when he had assured himself of his hoid on his special counselor who had let
him cling to her arm, he asked her where she lived. Although it was clear to
all other children that the counselor’s room was three doors from their dor-
mitory, his deep isolation had to lift before he could envisage her as a living,
personal entity.
This breaking through of his isolation was apparently meaningful to him
and he feared its return because his ability to maintain contact was still
very tenuous. The arrival of a new boy in the dormitory became an imme-
diate threat to him. However, he found means of reassuring himself; he
asked his counselor to come over to his bed and asked to kiss her good night
for the first time. He then told her a story which he called a “joke”:
Two people had started to go somewhere but soon found themselves back in
the same place from which they had started. His insecurity and fear that the
newcomer would set him back with his counselor to where he had started
showed that he still lacked faith in the reliability of human ties which he had
just learned to appreciate.
He became more aloof for several days, but then realized that his fears of
 BETTEJXEIM AND SYLVESTER 195

abandonment were not justified. This gave him the courage to display re-
gressive behavior for the first time. Though prompted by the threat of a
newcomer, this regression was actually progress, since he experimented ac-
tively with his ability to cope with vicissitudes in human contacts. Only
with his counselor did he began to act like a small child. In baby talk he
called her his mother, saying, “My mamma washes my hands for me. She
gets me clean socks.” He asked her to help him dress and to spoon-feed him.
He was permitted to experience this primitive child-adult relationship. Two
months later, baby talk and desire for spoon-feeding were given up spon-
taneously and new aspects appeared in his relationship with his favorite
counselor. Formerly he could maintain contact with her only as his expec-
tations of immediate and tangible gratification were fulfilled. Now the rela-
tionship to her became time-s tructured. His helplessness, the primitivity
and urgency of his needs made him desire the permanency of her support.
While walking close to her he said, “I am going to hang on to your arm for
the rest of my life.” I t took a whole year for him to develop a feeling of close-
ness to two adults, his counselor and his teacher. With the rest of the staff,
he got along without conflict since he recognized that they served useful
functions.
The relative freedom in the therapeutic milieu remained unacceptable to
this boy so long as he lacked inner control and the ability for self-regulation.
For many months after entering, he complained that the School was not
strict enough. Everyone, including himself, was being too spoiled. H e
praised the disciplinarian spirit of the orphanage from which he had come.
In this way, he expressed the fear of his own as yet unintegrated impulses
which at the School were no longer controlled completely by outside rules.
In his eating habits, he experimented with gratification and control of
Primitive impulses. In addition, through these eating habits he tested the
attitudes of the significant figures of his new environment toward his needs.
The boy, who had been well fed and of normal weight upon admission to
the Orthogenic School, began to overeat, to suck his thumb, and complain
that the staff tried to starve him. Gratification of primitive needs alone gave
him a sense of security and means of emotional expression. In eating he
also found compensation for the barrenness of his existence, which had to
remain limited so long as he could not avail himself of the opportunities for
Satisfaction offered in the therapeutic milieu. H e either insisted that the
adults force him to eat, or he ate incessantly. Awareness of his lack of inner
control and judgment made it necessary for him to have his devouring tend-
encies constantly permitted and regulated by others.
He had to check up on the food supplies in kitchen and store rooms to
make sure that he could expect continued gratification. This evidence had
to be tangible. When he noticed once that the milk supply was lower than
1% A THERAPEUTIC MILIEU

usual, his doubts could not be dispelled by verbal assurance; he had to wait
around until the milk was delivered.
After he had overcome his starvation fear, he became secure enough to
regress once more, and actually recapitulated to the feeding of an infant. He
had the courage to discover a baby bottle with nipple which had been on the
kitchen shelf since his arrival, and said, “What about that bottle?” When
asked, “What about it?” he answered, “I thought 1 might put some milk in
it.” He was not prevented from doing it; he used the nipple, then discarded
it, but persisted for several days in drinking out of the bottle. Then he began
to suck milk out of bottles through straws and for a long time carried a
milk bottle around in school and on the playground.
For nearly a year his incorporative needs had been met unconditionally
in quantity and form of gratification, before he showed spontaneous attempts
to control his gluttony. He began to show some discrimination with regard
to food, then he refused second servings, often of dishes he liked best. With
self-imposed limitations, his wish for adult control of his eating disappeared.
He had begun to have mastery over his primitive desires.
Certainty of unconditional gratification by others and his trust in his
ability to master his impulses had to be firmly established before he showed
awareness of the needs of others, which is essential in establishing any true
interpersonal relarionship. Such awareness first centered around eating, the
function of such great importance to him. He began to arrange tea parties
in which he himself prepared and served all the food. He showed great con-
cern that everybody should have enough to eat. These parties were at first
limited to his favorite counselor, the person who for a long time had satisfied
all his desires. Then he stopped grabbing tood irom the plates of the other
children and gradually included them in his parties.
Since there had never been any pressure on his table manners, the spon-
taneous changes in this area are significant indications of his inner changes.
His greed, his noisy smacking and sucking, gave way to the eating habits of
a normal child. Thumb sucking was relinquished for the socially more
acceptable chewing of gum. Personality changes paralleled this process of
arriving a t mastery of primitive needs through their unconditional gratifi-
cation. While initially his time was spent mostly in daydreaming, he gradu-
ally began to participate in active sports, learned to swim and play baseball
and showed pleasure in these achievements.
After two months at the School, his artistic ability spontaneously came
to light. His first artistic productions had a bizarre quality and were mainly
elaborations of death and cemeteries. While he had up to then continuously
disturbed the classroom by hyperactivity, noisiness, and frequent temper
tantrums, he now began to isolate himself in painting when the pressure
became too great. This temporary and self-chosen isolation was permitted.
It made his classroom experience more acceptable to him and to the others.
 BETTELHEIM AND SYLVESTER 197

The topic of his drawings changed; while he still needed occasional retreat
from the classroom situation, he no longer drew cemeteries but maintained
Some contact with the class by elaborating on the topics of the moment by
painting farmers in the field, Indians, and animals in an aquarium.
. His painting lost none of its imaginative and creative qualities. He derived
much personal prestige when the principal asked him for one of his paintings
for his office; and on the next day he offered paintings to others, indicating
that he had accepted the status they were ready to give him. He began to
show interest in his clothes and accepted his counselor’s suggestion to select
them personally. In the store, he showed fear of this personal responsibility
which had been delegated to him, but immediately utilized the experience
of being respected as an individual. During this shopping expedition he
talked about his fears for the first time and told his counselor that he often
asked her to sit on his bed a t night because he worried about death at that
time.
Gratification of primitive needs had made possible the emergence of subli-
mation. He was permitted to use his artistic talent to master the classroom
situation. He received prestige and praise for his painting. These freed his
intellectual abilities, and in ten months he made academic progress equiva-
lent to fourteen months.
The inability to connect present action, past experience, and future ex-
pectation led to many instances of confused and explosive behavior because
regular repetition of routine at the orphanage had made the boy’s life an
empty’’ continuum. In the absence of meaningful experiences,his existence
(<

had not been structured into past, present, and future.

Maturation as a historical process can proceed only if the child’s life ex-
perience is structured in the dimension of time. Although in the therapeutic
milieu children are not overwheimed with too many activities, still the boy
complained that there was too much to do. Holidays are made enjoyable in
a casual way, to avoid over-excitement. Instead, small everyday activities
are made carriers of interpersonal relationships. Although he did not yet
know what made one day different from another and was still unable to
react to the events that structure everyday life, he responded to the major
event of Easter. He accepted the present and took part in the egg hunt. H e
Was cautious and not too enthusiastic, but for the first time expressed con-
cern about a future event: he wondered about Christmas and asked whether
it would be possible for him to participate in its celebration and what it
would be like. H e could already envisage an event in the future but was able
to tolerate it only on the assumption that it would be similar to the ex-
perience in the present which he could accept. He wanted to be sure it would
not necessitate new adjustments.
Hallowe’en he enjoyed tremendously. He now took the sources of pleasure
in his present existence for granted. On Thanksgiving Day he complained
198 A THERAPEUTIC MILIEU

that while living in the orphanage, he had had no fun on holidays. H e was
now able to appraise his present life in terms of his past, and said “This is
my first real Thanksgiving.” He went on to complain that a t the orphanage
the children “never did anything.” They just had a meal like any other day.
Then he reminisced about Hallowe’en. His story was rather jumbled but he
had begun to see his life in the therapeutic milieu as a sequence of meaningful
and variegated events which he had the courage to face. He looked forward
to Christmas as a new “different” holiday. Structuralization of his existence
into present, future, and past was taking shape.
In the service of mastery of the new situation, all mechanisms that had
proven their adequacy were activated. New clothes had begun to give him
security through prestige. Accordingly, on Christmas morning, he was the
only boy who took great care to dress in his best outfit. His tolerance a t see-
ing others receive gratification and the ability to postpone his own gratifica-
tions, were recent acquisitions. His behavior was in line with them. H e went
to the fireplace where the stockings were hanging, and instead of grabbing
his presents, he insisted on telling the other children about what he found in
his stocking and admiring what they found in theirs. Then he very slowly re-
packed all the presents in his stocking. I t seemed to the adults that he had
not noticed a sled and some other presents and they pointed these out to him.
He replied harshly and ran out of the room, muttering to himself, “This is
enough. I cannot stand more of this.” Later, in the afternoon, he unpacked
some of his toys and started to play with them.
In a previous step of his rehabilitation, unconditional gratification of his
seemingly boundless needs had been therapeutically indicated. This per-
mitted recapitulation and gratification of infantile expectations and es-
tablished the basis for personality growth. Once he had learned that food
is always made available and that presents do not disappear, he could make
a further step. His new capacity to permit himself gratification was a new
achievement. I t represented ego growth even if guilt about receiving it may
have prompted him to postpone gratification.
Therapeutic response from the adult had to be in line with the status of
his ego development. Because he was not forced to deal with his gifts accord-
ing to conventional adult expectations of gratitude, he was really able to
enjoy the gifts-in his own time. Thus the adults’ respect for the patient’s
self-set limitations again represented unconditional recognition of his auton-
omous tendencies. Through such attitudes of the adult, the boy derived a
sense of personal integrity from incidents in his everyday life. This modified
his conception of himself and established self-esteem. He became able to
face the “bad” past and also developed trust in a benign and manageable
future, while he took his present existence for granted.2 Two successive
It should be mentioned that in children whose past experiences have been less malignant, the same
process leads to the emergence in memory of the positive factors in their past lives.
 BETTELHEIM AND SYLVESTER 199

dreams which he spontaneously related to his counselor illustrate this.

In the first dream, he was king of the universe, Superman. He had a
million dollars and ruled everyone. In the second dream, he went to visit
the orphanage. He was in the pool (where the older children had thrown him
into the water and never given him a chance to learn to swim). He showed
them how well he was able to swim and dive. All the children sat around the
pool and admired him and liked him very much.
The first dream shows how he attempted to compensate for his lack of
personal status in the orphanage by ideas of omnipotence. In the second
dream, his recently acquired real achievements, swimming and diving, give
him prestige among those with whom he used to have none. Thus the new
strength permitted him a more assuring perspective on past and future.
While the past had been bad, a similar situation would not again find him
helpless.
He learned to see his past in a light which no longer overwhelmed him.
Trust in his ability to master situations which once had overpowered him .
made his outlook of the future realistic and therefore more optimistic. A
similar change occured in his daydreams: instead of being a great dictator
and Superman, he now daydreamed about becoming a street car conductor
after having lived in a nice foster home for quite a while.
During the year of his stay at the School, the boy made significant steps
in personality growth. Environmental attitudes which made such develop-
ment possible were to him personified in the first counselor who had gratified
his dependent needs, permitted him defensive activity, and mediated be-
tween him and the outside world whenever he needed such help. As he ex-
perienced the implications of interpersonal relationships in his contacts with
her, his total human environment began to take on shape and structure.
When he came to the School, all he knew about people was that there are
small children, and big children who tell the small ones what to do. Human
interaction was a matter of domination through strength or material posses-
sions. For a long time, contact with other children consisted in forceful at-
tempts to take their toys. This behavior was dented when, on St. Valentine’s
Day, he unexpectedly received valentines from some of the other children.
He was happy that he should have made friends. Gradually, he became able
to share his toys occasionally, and there was a lessening of the inner struggle
Which first arose with such performance.
He was surprised that he had found a new modus vivendi with other chil-
dren and searched for an explanation of their kindness. He came to the con-
clusion that “thp children here act right because the grownups treat them
This was his first recognition of a benign hierarchy of human inter-
relations. Such awareness was possible only because he had experienced it
in his contacts with the counselor.
Since he was no longer isolated, the slowness and blocking disappeared
200 A THERAPEUTIC MILIEU

which had been equivalents for depressive reactions. The desire and ability
to communicate gave new meaning to his artistic creations; he discovered
spontaneoulsy that personal ties were the source of his new strength. He
told the psychiatrist that he had much more energy now and explained,
“Before, I thought that I could get energy and strength from food only;
now I know that I get energy from other children, counselors, baseball,
swimming, and drawing, that is, if I make a picture for somebody.”
In a later interview, about one year after admission to the School, he ex-
pressed his contentment in ‘a fictitious telephone conversation. As the chair-
man of the board of directors, he called the School’s principal to check up
and offer help. He asked, “What do you need for your children? Candy,
paper, paint, crayons, nothing? They know you have all they need? That is
good. Good bye.’’
He became eager to understand the relationship of grownups to one an-
other, since he now knew what adults have to offer children and what
children may mean to each other. Their relationships were no longer empty
or overwhelming and threatening, and he could therefore accept them. He
11
stated with great pride that he now knew what grownups were-they act
like ladies and gentlemen. They go to college, they care for children, they
like children. I will be a grownup too someday, but not for a long time.”
He had acquired a well defined reference frame and can be expected to pro-
ceed further in growth.

Case 2:3 This case, like the first, is also characterized by a child’s desper-
ate effort to cope with an unbearable reality. The outward signs of this strug-
gle for mastery were hyperactivity, destructiveness and stealing, severe
inhibition of intellectual functioning, and extreme suspiciousness. These
symptoms appeared first when Mary was six years old. She had been trans-
ferred to a foster home from the nursery where she had lived after her
parents had deserted her a t the age of three. While a t the nursery, she
had not presented any manifest problems, but in the foster homes her be-
havior became progressively more difficult and led to many changes in homes
until she came to the Orthogenic School a t the age of nine. Her disturbed
actions were only the surface ripples of her megalomaniac fantasies, evi-
dence of the unavoidable clashes between external demands which she could
not fulfill,and her magic world to which she could no longer successfully re-
treat.
Psychiatric study before admission to the School showed that she was
quite detached from the many adults and children with whom she had
lived. She was utterly confused about their identity. Physiological activities
Credit for most of the direct work in rehabilitating this girl is due to Miss Marjorie Jewel1 and Miss
Joan Little.
 BETTELHEIM AND SYLVESTER 201

like eating and sleeping were not gratifying experiences, but duties imposed
by rules or the wishes of others. She hardly knew what playing meant. She
said, “Where I live, there is a doll buggy, but I must not touch it.” She
explained, “Once I was a baby, but I was never wheeled in a buggy.”
When asked where she lived, she answered, “In a place where you get
clean clothes after playing. Then you take a nap and eat sometimes.” She
was unable to name any of the children or adults in the orphanage. When
asked whether she had a friend, she said, “They tell me that John is my
friend.” When asked who took care of her, she replied, “A nurse, that is a
lady, any lady.”
A large segment of her life was spent in autistic fantasy. She said that she
was a good girl because she did not bother anybody. Nothing bothered her
either since she, and everything around her, was magic. She only had to
open her window, say goodbye to the children, then she could. fly to God who
was nice always.
A few days after admission Mary said she liked the School. “It is like in
the nursery before, but it is better, because it is all in one. The school is
just here and not five blocks away.” Through simplification in denial of
any difference, distance, or discrepancy between the constituents of her out-
side world, she reduced her new environment to manageable proportion. In
the foster homes she had had to protect herself from being overwhelmed by
the multitude of external events, since the empty existence of her early
years had not equipped her to deal with them adequately. But the autistic
mechanisms which she applied did not help her to master the persistent
demands of reality; when she attempted to withdraw more deeply, her
inadequacy only increased and anxiety resulted. Her confusion which led
to constant misinterpretations and contaminations seemed to reduce her
intellectual functioning to a near feebleminded level.
In the School her need to avoid anxiety determined the nature of her
initial adjustment. This need was met as her spontaneous methods of mas-
tery remained unchallenged by external pressure. At that stage, the existence
of actual sources of satisfaction and stimulation in the therapeutic milieu was
of value for her only became she was not forced to combat external pressure.
Still, the presence of such factors was essential from the beginning for her
rehabilitation. They had to be available when she was ready to take ad-
vantage of them. Opportunity for stimulation and gratification distinguished
the therapeutic milieu from the barrenness of nursery life which had led to
impoverishment of her personality, while freedom from the pressure which
had made her foster home experiences so deleterious, precluded necessity
for further confusion and withdrawal.
Since she could not, a priori, expect conditions in the external world
to be different from her past experiences, she had to apply her old mecha-
202 A THERAPEUTIC MILIEU

nisms of mastery in the new environment. Her courage to explore reality

had first been severely curtailed by lack of stimulation in the orphanage,
and later by her experiences in foster homes. Protective withdrawal into a
world of all-powerful magic was therefore maintained at the School until
she developed sufficient confidence in herself and trust in others gradually to
modify her defenses.
Mary had not learned to live without magic protection, and now met
benign, relatively powerful figures. In proportion to the abject degree of
her helplessness, she needed protective figures of such strength as could only
be furnished by endowing them with mapic powers. Under the aegis of these
figures, she could venture forth to test reality with greater comfort and se-
curity. Thus, in a way, she tried to establish magic contact with what seemed
to her the most important figures in her new environment, the principal and
the psychiatrist. I n order to be able to retain them as “magic” figures, all
realistic contact with them had to be avoided, and they had to be both deper-
sonalized and unified. To do so was also in line with her past efforts to organ-
ize her world by recognizing persons only as carriers of useful or dangerous
functions. This tendency she demonstrated by depriving the two figures,
the principal and the psychiatrist, of the only personal characteristics of
which she was aware, their names. She contaminated them into “Dr. Bettel-
ster.” Whenever she used this contamination, it designated both of them in
the magic and protective functions she assigned to them. She refused to
recognize them as persons and avoided personal contact. Because she re-
buffed their efforts, contact was discontinued.
She began to approach the principal about one of his functions with which
she had become familiar-his role as mediator. She established a routine of
complaining to him, remaining aloof at the same time. She did this in line
with her magic expectations, and not in terms of a realistic interpretation of
his function. She invariably expected him to take her side, protect her, and
punish the others. The fact that she received protection only when she
needed it, and that other children were not reprimanded just because she
complained about them, did not change her conviction of his role as her
special protector. When other children expressed fear about events which
were beyond control, she reassured them with the statement, “It cannot
happen here because of Dr. Bettelster.” Gradually, after she had established
personalized contacts with her favorite counselor, she separated the psy-
chiatrist from the principal, still adhering to the conviction of their inherent
identity: she then called the one Dr. Bester and the other Dr. Vester. Much
later, after she had finally found true security in the relationship to her
counselor, it became possible for her to divest them of some of their presumed
magic characteristics, to accept them tentatively as real, and recognize them
as two different persons with different names.
 BETTELHEJM AND SYLVESTER 203

Under the magic protection of the most powerful figures that she had
created for herself, she was able to explore segments of reality and to ap-
poach a relationship with her counselor. In the meantime, the other children
had to remain anonymous and unreal because to acknowledge their presence
would have interfered with her need to claim her counselor for herself.
Gratification of her most urgent needs became the basis for her human
contacts. For many months she over-ate, staying in the dining room after
the others had left and scavenging for food in spite of the large helpings she
had already eaten. After every meal, she wrapped food in a napkin to take
with her for fear she might be hungry before the next meal. Whenever a
course was put on the table, she jumped up excitedly and looked at her
counselor for reassurance that she would get more food. Frequently she ate
directly from the plate without utensils in order to finish in time for a third
and fourth helping. No limitations were put on her needs. After a month
she required fewer helpings of food. Now her eating habits did not reflect
greed but became distinctly babyish. She sucked her food and occasionally
spat it out. Then she started to carry a small j a r with her in which she kept
a ration of candy. Her eating habits changed only after she had formed indi-
vidualized relations to her counselor and to some of the children.
She did not tolerate any closeness and had to be permitted to “float
around” in the School for some time. Out of the confused anonymity of her
existence, familiarity wit$ carriers of useful functions emerged slowly.
Children remained anonymous to her much longer than adults. A friend
was a child who was “bigger and can beat you up; you go to her bed.” But
she was hardly able to distinguish one child from another. T o her, they were
nameless and existed only if tangibly present. She spoke of them as “that
girl,” and the only way she called to them was “Hey, you.”
o n a walk with a counselor, two of the other children ran ahead and were
out of sight for a few minutes. When the rest of the group caught up with
them, she said without any sign of being perturbed, “Oh there they are. I
thought they were dead.”
When she began to individualize the children, it was in terms of their
attitudes toward the counselor to whom she had become very attached. She
consistently expressed her disklike for some children who called this counselor
names. In her first attempts to make friends, she adopted toward other chil-
dren those attitudes which she expected from her counselor in fantasy, and
had to be restrained from giving away all of her possessions. Her tendency
to concede to any demand made by other children was inappropriate and
had to be modified.
Confusion had been the outcome of her attempts to orient herself toward
people around her. Similar disorientation showed her helplessness in other
areas. Since she had lived in many parts of the city without sufficient aware-
204 A THERAPEUTIC MILIEU

ness of reality ever to find her way about, she was utterly lost in the neigh-
borhood of the School. She showed pseudologic attitudes when she claimed
to know every person and every building, in attempting to compensate for
her overwhelming ignorance by such confabulation about persons and places.
She claimed to recognize old acquaintances and insisted that she had lived
on that or the other street. Isolated actual recollections appeared later and
then in connection with functions and activities she had begun to master
at the School.
Conventional concepts of time meant nothing to her and she manipulated
time purely in terms of her own needs and tensions. On July loth, she re-
called that her birthday had been on “June two and three” (June 23rd).
This meant to her that her next birthday would be “in two or three days.”
Whenever she acquired any valid and usable knowledge, she used it compul-
sively to orient herself. When she was already sufficiently settled a t the
School to wish to remain, reassurance that she could stay as long as she
wanted was insufficient. She had to orient herself by applying the terms of
the seasons she had just learned about in class, and asked repeatedly: “Will I
be here in the summer? Will I be here in the winter?” repeating the seasons
many times. I n this way, she sifted her new knowledge in terms of its value
for the reassurance she needed. Facts were accepted and retained only after
she had tested their usefulness for her immediate needs.
When she first began to experience activities and events in the external
world as more gratifying than complete immersion in fantasy, she could not
stand the tension of any delay in the succession of external occurrences. If
she wanted to buy something, she could not accept the fact that stores were
closed in the evening. She could not stand any moment without activity and
continuously asked: “What are we going to do now?” Before an answer
could be given, she had already wandered to some other subject and she
was unable to comprehend what was said to her.
The same pressure appeared in her manner of talking. While she had been
quiet and uncommunicative when she first came to the School, with turning
to reality, her speech became rapid and explosive. She deleted syllables and
ran words together, so that her talk was difficult to understand. Of this, she
was initially unaware. Then she became frustrated about her inability to
express herself. Her sentences became even less comprehensible as she now
interspersed them with recurring exclamations of disgust. She finally real-
ized this when she stopped herself in the middle of a sentence, looked apolo-
getically at the counselor and said, “I can’t even speak the English lan-
guage. I can never say what I want to.”
A process of gradual organization started in and around her daily contacts
with her special counselor. At first her counselor was a nameless one of many.
Her appreciation was unspecific as to source and form of gratification. She
said, “I like them, they are good to you.” A few weeks later, she dimly
 BETTELHEIM AND SYLVESTER 205

recalled her counselor’s name; but she still could describe her life a t the
School only in a stereotyped enumeration of activities which were related
solely to herself, such as eating, bathing, going to bed. She mentioned other
children only in terms of their interference or noninterference with these
activities.
After about a month, contacts with the counselor centered around such
simple activities as Mary initiated herself. She demanded to be carried,
to be cuddled and fed. When she saw the counselor after a short absence,
she shouted, “I love you,” hugged her and playfully bit her. Her attitude
then did not yet express the interpersonal relationship of a nine-year-old,
but was the possessive clinging of an infant.
After about six months, her haunted, sober expression occasionally gave
way to real smiling a t her counselor. In these moments, she seemed to be in
contact, her voice was natural, she finished her sentences and could be
reached by the counselor’s reply.
I t was then, in her contacts with the counselor that she energetically and.
actively went about the task of getting order into her immediate world.
Temporarily her activities assumed a compulsive character. She was first
concerned with the order of things around her and started her new activity
around eating situations. She cleaned her candy box repeatedly, stacked
candy bars according to color and size, counted them and said spontaneously,
“This is fun.” Then she cleaned her shelves vigorously, arranged and rear-
ranged her toys and wanted her clothes laid out exactly and neatly for the
next morning. Her bed had to be perfect and she liked to sweep the floor
around it and even underneath. It was as if orderliness in objects related to
her had to precede inner order.
Her counselor made some comment about the amount of cleaning she
did and she replied that she liked to clean, and added, “Then when I grow
up,” and stopped. When asked to go on, she said, “Well, it was silly and I
know it is not true, but I thought that I would have all my cleaning-up done
by the time I grow up.” Thus she experimented with her ability to compre-
hend and master the objects around her in their relation to each other and
to herself. In this experimentation with external order, she achieved mastery
Over one sector of the outside world. As she became able to internalize this
achievement, she made her first steps in integration.
I t should be kept in mind that her activity emerged spontaneously within
the setting of her contacts with the counselor in which, within a reference
frame of predictable and maintained interest, she had already experienced
not only order, but also unconditional gratification.

Conchiom., The aim of any psychotherapeutic procedure is to help the

Patient toward adequate mastery over inner and outer forces.
The importance which milieu factors have for causing emotional disturb-
206 A THERAPEUTIC MILIEU

ances in childhood is well established. It is also realized that manipulation

of milieu factors can be used toward the rehabilitation of emotionally dis-
turbed children.
In direct psychotherapy of children, recognition is given to the fact that
shaping the individual’s biological needs in the earliest years is of decisive
importance for later personality structure as well as for prognostic considera-
tions. When distorted growth processes can be recapitulated within the
benign setting of the psychotherapeutic relationship, symptoms become un-
necessary, personality structure changes, growth phenomena appear, and
psychotherapy can be considered successful.
Similarly, emotionally disturbed children can be helped through living in
a milieu which is aware of the factors that promote restoration of function
growth, and new integration. The two children described improved in the
particular therapeutic milieu because there insight was translated into un-
interrupted action extending over twenty-four hours a day. The children
showed improvement because they lived in an environment which, from the
start, provided them with a stable frame of reference. While the adults
maintained the interpersonal hierarchy in all their dealings with the children,
their actions always remained spontaneous within the indications set by
the psychological reality of the individual child. This was the spirit in which
every child received such gratification as his instinctual and defensive needs
dictated a t any given moment.
The use of the continuously maintained one-to-one relationship within a
therapeutic milieu as one of the many aspects of milieu-psychotherapy is
stressed.