Bratter still loves quoting Bratter.
Confrontation-A potent psychotherapeutic approach with difficult adolescentsAdolescent Psychiatry, 1/1/2008 by Bratter, Thomas Edward, Sinsheimer, Lisa
Abstract
http://findarticles.com/p/articles/mi_q ... 1322/pg_12This chapter describes the use of confrontation at the John Dewey Academy, a college-preparatory therapeutic boarding school. The treatment utilizes caring confrontation and positive peer pressure within a therapeutic community setting. The authors discuss the conceptual basis for the use of confrontation, drawing upon the literature about therapeutic communities. They offer a rationale for the efficacy of this psychotherapeutic approach in a population of bright adolescents who are resistant to traditional treatment. They illustrate the use of confrontation with an extended excerpt from a therapeutic group. Countertransference issues related to the use of confrontation are also discussed.
Toward a definition of clinical confrontationNunberg (1955) provides a reasonable definition of confrontation when he proposes the psychoanalyst "[call] the patient's attention to his inner conflicts, the sources of which are not known to either of them, and asks him to be helpful in discovering the unknown, the repressed. Thus, from the very beginning, the aims of the analyst are opposed to those of the patient, to the wishes of his repressing ego" (p. 123). Nunberg disagrees with Devereux (1951), who explicitly states that confrontation "yields no insight, and merely focuses the attention of the patient on something which he perceived but failed to register-or refuses to acknowledge openly" (p. 69).
Carkhuff and Berenson's (1967) definition has stood the test of time. They report that confrontation helps the person understand:
himself, his strengths and resources, as well as his self-destructive behavior....It is a challenge to... become integrated....It is directed at discrepancies... between what the client says and does...and between illusion and reality....It implies a constructive attack upon an unhealthy confederation of miscellaneous illusions, fantasies, and life avoidance techniques in order to create a réintégration at a higher level of health (p. 171).
Confrontation in self-help therapeutic communitiesDuring World War II at Henderson Hospital in the Belmont Social Rehabilitation Unit in England, Rapoport (1960), a sociologist, was the first to describe group psychotherapy to be "reality confrontation." Shankman (1978) provides a description of the self-help therapeutic community (TC), as illustrated by Casriel (1963); Bratter (1978); Bratter, Collabolletta, Fossbender, Pennacchia, and Rubel (1985); Glaser (1974); Sugarman (1974, 1986); and Yablonsky (1965), in which recovered persons act as catalysts and responsible role models:
The TC might best be described as a school which educates people who have never learned how to live or feel worthy without hurting themselves and others. The therapeutic community helps people who have tried again and again to get what they wanted from life and have continually defeated themselves. The principle combines the basic and universal human values of knowledge, love, honesty, and work, with the dynamic instrument of intense group pressure, in order to recognize and help correct personality defects which prevent people from living by these values. The results lie in rehabilitation so that the individual may reenter his or her community as an independent and productive person (p. 156).
When describing self-help peer psychotherapy, Van Stone and Gilbert (1972) candidly describe the brutality of confrontation in residential therapeutic communities that are run by recovering addicts. Confrontations needed to be harsher in these adult communities than they would be with teenagers, and justifiably so:
[Confrontation is] a kind of group therapy in which each member is...presented with candid, personal facts regarding every observable behavior or attitude recognized by the group as being self-defeating or dishonest. If the member.. .attempts to explain or deny any observation, he is ridiculed.. .and insulted as his fellow members hammer away at the distorted ideas that he offers in support of his damaging behavior patterns. Intellectual insight or genetic self-interpretations are derided as an escape from responsibility for current behavior. Honesty, trust in the group, realistic self-assessment, appropriate emotional release, and changed behavior, in particular, are rewarded by sympathetic counsel and encouragement from fellow members (p. 585).
The professional community initially characterized confrontation as cruel. Maslow (1967), the progenitor of humanistic psychology, recognized the effectiveness of confrontation after attending groups at Synanon, the first exaddict-administered therapeutic community. He wrote, "people are ...tough.... They can take a.. .lot... .I've suggested that a name for this might be 'no crap therapy.' It.. .cleanfs] out defenses [and] rationalizations." (p. 28). Ruitenbeek (1970) agrees with Maslow, describing the essence of this technique as an "insistence upon total honesty....No rationalizations...are allowed" (p. 166). The clinical challenge of confrontation is to help the youth commit to accept responsibility by converting noxious emotions into constructive acts via the internalization of positive values. Self-respect and success become positive addictions.
Confrontation is painful because it penetrates protective barriers. Using a psychoanalytic orientation, Adler (1985) defines confrontation as an attempt to "gain a patient's attention to inner experiences or perceptions of outer reality of which he is conscious or is about to be made conscious" (p. 122). Sifneos (1991) cautions that the therapist who uses confrontation needs to:
"be convinced that the patient is able to withstand [much] stress... .[Effective] confrontation must be based on the therapist's observation about a series of paradoxical behavioral patterns, contradictory statements....It must motivate him to look at himself from a different point of view" (pp. 374, 382). Cohen (1982), who reconciles confrontation and psychoanalysis, provides a comprehensive synthesis when he contends that "confrontation analysis is a method of investigating, analyzing, and evaluating human behavior in the context of interpersonal interaction. It.. .contains a theoretical framework within which to understand the evolution, maintenance, and modifications of personality dimensions" (p. xv).
Countertransference issuesCollabolletta, Gordon, and Kaufman (1998) stress that the therapist's intent determines whether the confrontation is therapeutic or an abuse of power: "When the psychotherapist's intent is to promote change, this kind of confrontation becomes caring and constructive." When the intent is to prevent a student from engaging in destructive, dangerous, and deceitful acts, compassionate confrontation becomes the most potent expression of responsible concern. A skillful confrontation provides prima facie proof of the therapist's care and emotional investment.
The therapist needs to be mindful of potential countertransferential contamination when using this technique. Only the confronter knows personal motivations; thus, one must understand the psychodynamics before confronting. Unresolved countertransferential issues can provoke cruel confrontations. Giovacchini (1985) notes that adolescents can arouse disruptive countertransference reactions because of the intensity of their neediness and defiance, and warns that countertransference may destroy the treatment relationship, or it may lead to therapeutically beneficial insights. The therapist can feel jealous that these adolescents have emancipated themselves from middle-class restraints. Or, more likely, be disgusted by cruel and feel a need to punish the offender. Consultation with colleagues or a supervisor can minimize the likelihood of acting out a destructive countertransference reaction.
Sequence and principles of confrontationBratter (2003) asserts that "there are two sequential phases to confrontation: first, the unlearning of dysfunctional attitudes and acts and, second, learning healthy responses. Confrontation can penetrate the permissive and indulgent attitudes of families that [created] the psychopathology of alienation, deceit, irresponsibility, and self-absorbed behaviors" (p. 140).
Bratter (1977, p. 170) lists seven principles of confrontation psychotherapy:
1. Attack the malignant and dysfunctional aspects of behavior.
2. Penetrate the facade of justification of behavior.
3. Force individuals to accept responsibility for behavior.
4. Help persons evaluate their behavior.
5. Assist individuals to be aware and to anticipate the consequences and payoffs of their behavior.
6. Challenge persons to mobilize their resources.
7. Define a direction so that persons can continue their growth and development.
How confrontation facilitates change in adolescents
Confrontation is a potent psychotherapeutic process designed to help the adolescent not only to recognize (and change) the self-destructive aspects of behavior but also to acquire skills that help actualize potential. In a group setting, peers offer insight and suggestions, thus providing the catalytic conditions necessary for selfexploration and improvement. Confrontation pierces the formidable protective armor of denial, deceit, and distortion. Meeks and Bernet (1990) note "accurate confrontation is much easier in the inpatient setting than it is in the treatment of outpatient adolescents" (p. 578). Johnson (1985) views confrontation as supplying an "observing ego" (p. 255). Brook (1996) believes that confrontation helps adolescent "group members...to confront denial and accept responsibility for their actions" (p. 258).
Bratter (1972) describes the therapeutic thrust of a confrontation-group orientation:
Using a confrontation-teaching-interpretative-reasoning approach, the group demonstrates to the [member] the irresponsible and self-defeating aspects of...behavior [and]...begins to understand the consequences of his acts and attempts to become more responsible to himself, others, and society. Emphasis is placed on the eigenweit (the relation to one's self)-i.e., the immediate experience. The individual must acknowledge his perceptions of the conflict, the problem, his irresponsibility, etc....
The individual, gaining the candid opinions and admonishments of his peers regarding the more destructive elements of his behavior, considers a new orientation and behavior (p. 309).
Confrontation can:
- * Expedite a behavioral change-i.e., stop dangerous and dysfunctional behavior.
* "Force" the adolescent to be accountable for attitudes and acts.
* Help students understand future consequences and payoffs for current behavior.
* Mobilize personal talents to actualize potential.
Confrontation utilizes provocative questions to stimulate self evaluation. Do your attitudes and acts help you to achieve your intermediate and long-term goals? How do others view you? Do you have self-respect? In addition, the therapist must elicit reactions from the confronted and group members about their reactions to the confrontation. Garner (1970) urges the therapist to ask frequently, "What do you think or feel about what I told you?" (p. 231).
Helping each other while helping the selfTo minimize the impact of negative countertransference reactions, since a significant age differential exists between adolescents and the group leader, peers are encouraged to do most of the confronting. Volkman and Cressey (1963), among the first to recognize the importance of self-help confrontational psychotherapy groups, write:
The most effective mechanism for exerting group pressure on members will be found in groups so organized that criminals are induced to join with noncriminals for the purpose of changing other criminals. A group in which criminal "A" joins with some non-criminals to change criminal "B" is probably more effective in changing criminal "A" (p. 139).
Brager (1965) notes increased self esteem in group members when they confront peers to better themselves. Reisman (1965) labels this treatment dynamic as "the helper principle," and notes that the helper often gains more from the helping process than the person being helped. Positive peer pressure traces its antecedents to self-help psychotherapy. Hurvitz (1970) reports that when peers are active,
they focus on the presenting problem, and assume that by following principles and methods of their movement, they will help each member solve his specific problem....They may ridicule and attack each other with great hostility and they may provoke aggressive and hostile feelings; however, peers regard such attacks and provocations as other's expressions of concern and concern (p. 44).
Use of confrontation at the John Dewey AcademyBratter, Sinsheimer, and Kaufman, in chapter 7 of this volume, have described the population and treatment philosophy at the John Dewey Academy (JDA). As they have said, JDA youth are "immune to traditional therapeutic and teaching techniques. They have erected formidable barriers and defenses which need to be cracked before they will think rationally... .Peers confront each other by demanding that each member accept accountability for immature, irresponsible, illicit, and self-destructive acts" (p. 73).
Compassionate confrontation: Rebutting the critics
When entering the John Dewey Academy, most students possess toxic attitudes that reduce others to objects to satisfy voracious narcissistic needs, self-entitlement, and self- aggrandizement. Both traditional therapeutic approaches and the administration of psychotropic medicine have proven ineffective. No chemical imbalance exists. Many Dewey youth have a virulent attitude that renders psychotherapy ineffective which explains why recidivism rates are high.
Critics contend that confrontation is controversial, counter therapeutic, and cruel punishment which often brutalizes persons-in-treatment. Confrontation attempts to modify irresponsible, impulsive, immature, stupid and self-destructive behavior. Confrontation penetrates denial, distortion, and dysfunctional attitudes. Critics protest, furthermore, that the use of confrontation is prompted by a negative countertransference reaction. Confrontation has been labeled "attack therapy" for pejorative reasons. Opponents of "attack therapy" do not understand is that confrontation has proven effective to eradicate malignant, dangerous, vicious attitudes and acts. While some critics condemn confrontation to be "cruel," they need to remember that Dewey students have engaged in dangerous, often death-defying behavior which demands heroic intervention. Unless the therapist can persuade the youth to avoid a collision course with disaster, there can be profoundly serious consequences. The primary goal of psychotherapy is to preserve life, so desperate and heroic treatment interventions are required for this difficult-to-treat population. When viewed from this humanistic perspective, confrontation connotes caring by the therapist who attempts to convince the adolescent to become more responsible, responsive, and respectful.
Similar to other medical procedures, there are abuses of confrontation psychotherapy which the authors acknowledge and condemn. The authors, therefore, do not minimize the noxious impact of confrontation when done for the wrong reasons.
There are similarities between the psychotherapist who confronts, the radiologist who medicates, the surgeon who operates, and the psychiatrist who prescribes psychotropic medication. Stated simply, these procedures are subject to abuse. In addition, each procedure attempts to attack malignancies. If the truth be known, confrontation is more benign than other medical approaches. The surgeon, radiologist, and psychiatrist do more physical and permanent damage under the guise of medical treatment than does the therapist who confronts. Interesting, these professions escape criticism because the end is thought to justify the means. There are more malpractice suits against medical professionals than psychotherapists who confront.
Confrontation psychotherapy: A Case studyAs an illustration, we present an excerpt of our group process. Prior to attending JDA, Jason had been diagnosed as having schizoaffective disorder and had been prescribed a cocktail of psychotropic medications, including amphetamines, antidepressants, and anxiolytics. Jason's father died when he was twelve, and his mother was in remission from a brain tumor. He witnessed several people jumping to their deaths from the World Trade Center towers during the 9/11 terror attacks. Two years ago, Jason learned he had the same hereditary cardiac condition that caused his father's premature death, and he underwent the implantation of a pacemaker-defibrillator.
Considering his history, post-traumatic stress disorder might have been a more appropriate diagnosis. Regardless of diagnosis, however, this boy had clear explanations for his choice to suppress his feelings and for his decision not to trust others. He struggled with a continuing sense of abandonment and betrayal, stemming from his father's sudden death. During the 18 months that he was at JDA, he remained closed off from other students and staff. The following is a fragment of a group session in which first the group leader and then the other members of the group confronted Jason on his behavior and their reactions to it. Before convening this group and implementing this confrontation, the group leader discussed the treatment impasse extensively with colleagues. The intent of this confrontation was to precipitate a crisis, forcing Jason to change or to leave.
Leader: Jason, recently adults have asked if I think you are organically damaged since you refuse to heed repeated warnings not only to change but also to become a contributing member of the community. I admit that for the first time I mentioned that perhaps they are right and I am wrong. Maybe you are damaged goods and are incapable of changing. You might be the first student in our twenty-year history who needs medication to function. I intend to recommend to your mother that you be evaluated by a psychiatrist who specializes in pharmacology.
Jason: I am not. You know damn well I'm not crazy and don't need that crap.
Leader: I no longer know what to think. What I do know is that you have been here for eighteen months, but haven't changed much. You still isolate. You still refuse to relate. You still don't trust anyone. You still are stubborn. But to your credit, you finally have started to do well academically. I think you hide in your academics by claiming you need to study six or seven hours a day.
Jason: Yes, but...
Leader: Yes period. Your classmates complain that you're a drag and a drain. They don't want to waste their time and energy reaching out to you and having you reject them. Ask them.
Jason: I've been talking to people. (He lists five students.)
Mary: Big deal. They are new students. None have been here longer than three months. What about us? We know you much better than they do. They don't know how to confront you. So you continue to play stupid games.
Laurie: I have no idea who you are. When you feel uncomfortable and threatened, you shut down. When my father died abruptly from a heart attack, just like your father, you never even said you were sorry. This is why I stopped pursuing you.
Jason: I don't want to talk to you because you don't want to talk to me.
Leader: That's a very mature response. You're right, but do you know why?
Jason: No.
Leader: You lie. You know damn well. Everyone is frustrated and weary. They have extended themselves by sharing experiences and confronting you. What have they gotten from you? Only silence and sarcasm. So they finally said to themselves, 'Fuck him. He's simply not worth it.' You quit. No, that's wrong. You never tried.
Allie: Tom's right. I quit six months ago. I gave you the benefit of the doubt that, underneath your defenses, you were caring. I don't believe that any more. You talk in a monotone. I cannot remember when I felt you cared. You are the most frightened and self-absorbed person I've ever met. I know why. When I came I was too scared to care. I had a damn good excuse. I had several abusive relationships with guys. I felt sorry for myself and saw myself as the victim. I was confronted that it was my choice. I chose to remain with these abusive jerks when I should have rejected them! It was scary to trust because I feared the worst. Yeah, I got hurt once or twice. I was knocked down. But I got up and tried again. And you know what? Today, I have the best friends I ever had.
Laurie: I don't blame Allie for not giving a damn. No one trusts you. You are nineteen. You continue to treat your mother like she's the enemy! You abuse your younger sister. None of us care whether you leave or stay. I pity you. You are too scared to be human. You are a poor excuse for a person.
Eddie: Jason, it's really that easy. You lack the guts to venture forth. You're a coward. I'd lie if I said I care because I don't. Blame yourself. But what frightens me is that I know if you don't do it at JDA, you never will. You will never be in an environment which is so caring and safe.
Paul: Eddie's understating your problem. Several of us believe you have major guilt, but lack the integrity to take accountability. Fuck your fears. Take accountability. Things can't get much worse.
Shirley: Do you know what I think the problem is?
Leader: No. Tell us.
Shirley: Jason does not believe you will expel him. You've threatened so many times to expel him that he thinks he's immune.
Eddie: Shirley's right. Jason knows you like bright students, so he's gambling since he has not done anything expellable, you'll let him graduate.
Leader: Jason, if this is what you think, your reality testing is flawed. Complete the next two weeks and then go home for the holidays. Think about what you will want to do with your life. And then write a ten-page essay why I should readmit you. Include in this document your guilt and what you will change.
Allie: Why wait? He thinks you are bluffing. He's not going to change. For the next two weeks, he will do nothing.
Leader: You're right, Allie. Jason, leave in three days. I will give you seventytwo hours to make arrangements because I doubt your mother will permit you to return home. My guess is that all the New York City homeless shelters are filled because it's cold, but I suggest you call them.
Paul: We're wasting our time. We have confronted you many times but you ignored us. You have made commitments to change, but you never have. You continue to joke and act nonchalant. You've done this for six months, so I agree with what Tom said at the beginning of the group. Maybe you just don't get it! I believe you lack the guts to come out from behind all the barriers you have erected. You will be a lonely guy who becomes bitter because no one will be knocking at the door asking you to let us in. Maybe you should watch Dickens' "Christmas Carol." You could become Scrooge.
Susan: I've kept quiet because I tried many times to reach out to you, but you always gave me shit. You continue to be obnoxious and confront others about dumb shit which tells everyone to stay away. I know when I confront kids rather than connecting with them, they get the message to stay away.
Leader: Sadly, I doubt if this group will have much impact. You have heard all this shit many, many times. This may be the last group you attend at John Dewey. I won't shed any tears if you do not return, other than we failed to help you in your time of desperate need. But Scrooge changed when he was much older than you are. Unfortunately, Scrooge is a fictional character. Maybe you ought to read Dickens when you go home. Unless you change by letting the sun shine in, you very well could become Scrooge. It would be tragic if you were to live a wasted life because you have been blessed with awesome intelligence. You could have been great. You could have improved the quality of life. But you won't unless you get the guts to show you care. It's late, but there still is time. The next month will be the most important in your life, because the decisions you make will influence you until you die. I hope for your sake, and that of society, you finally make the right decisions because this may be your last chance. Enough. I don't want to waste any more time. I end abruptly because I do not want to have closure. I hope you are scared because I am scared for you! You can win, but time is a precious commodity, which you lack.
Case follow-up
Following this group, Jason enrolled in a four-week wilderness program in an attempt to earn readmission to Dewey. During his stay at the wilderness program, Jason received notification of early-decision admission to a prestigious college of engineering, as well as word that he had been awarded a substantial scholarship.
While in the wilderness program, Jason was admitted early decision to a prestigious engineering college. We thought this would provide the incentive for him not only to return to John Dewey but also to confront his fears. However, when he returned from the wilderness program, Jason remained intransigent. He engaged in provocative behavior, which forced his expulsion for safety reasons. He "played" with the fire alarm. He "played" with the stove, turning it on and off. He asked the dean of students if he could set fires by using his bow and drill, a skill he had learned in the wilderness. His intent seemed obvious-rather than leaving school voluntarily, Jason wanted to be expelled. It seemed certain that the behavior would escalate if he were allowed to remain. The decision to expel Jason was in keeping with the treatment principle that there are consequences for behavior. Students, parents, and staff were notified before any action was taken, and no one disagreed with the decision to expel him.
The president was faced with the dilemma of whether, and how, to report Jason's behavior to the engineering college. One option would have been to hide behind the shield of confidentiality, but it was felt that unsafe behavior does not warrant confidentiality. Additionally, notification was justified because Jason dropped four courses, which, if not explained, would have resulted in his acceptance being rescinded. Finally, there was the importance of maintaining a relationship with this college so others could attend.
At the same time, the president was aware of his reactions to Jason, which included disappointment, betrayal, anger at not being appreciated for convincing the college to grant a generous scholarship, and rage at being placed in a most uncomfortable position. He knew no one would criticize him if he urged the college to rescind admission, but knew this consequence was extreme since the family could not afford to pay tuition. It is dubious if Jason would have attended college. After careful consideration, the president wrote a letter to the dean of admissions at the college, explaining the reasons for the expulsion, reviewing the factors in Jason's background that have made it difficult for him to succeed academically and socially, and recommending that he reapply to JDA and complete a postgraduate year before attempting college. Included in the letter were the following statements.
Please be advised.. .if I thought Jason were "too dangerous" or "too sick," not only would I notify _____college, but also would refuse to give him the option to return to Dewey....Jason's refusal to comply is motivated by fear to trust others and to be emotionally vulnerable, not defiance. The only time Jason cried was when he was confronted about his reluctance to trust.. .because he feared friends would abandon and betray him... .If permitted to attend college, I suggest Jason be required to continue psychotherapy. He needs to resolve his fear of intimacy, not because he is a threat to safety. Jason and his mother will receive a copy of this letter, so hopefully both will communicate with you. I warned Jason that [college] may rescind his acceptance....
I would be willing to accompany Jason for a conference, with anyone you think makes sense, to discuss options. Undeniably, Jason is a disappointment, but I hasten to mention that several have graduated in Jason's position needing to do more work therapeutically. In college, they excelled. His prognosis remains guarded....! conclude...by stating that he has learned much.
The president would have been wrong to suggest rejection essentially because the decision is that of the college, not the preparatory school. To recommend rejection would have been an abuse of psychotherapeutic power. Post hoc, the president knew that had he become retaliatory, his motivation would have been revenge for Jason's disrespect and lack of appreciation regarding his advocacy, which had resulted in Jason's being awarded a $160,000 four-year scholarship. Had he urged that Jason be rejected, which was warranted, Jason's future would have been ruined, because without a scholarship, it would have been impossible for him to attend college. The president retained his therapeutic integrity by reporting what happened, but refraining from recommending any action. The college decided to continue to extend its offer of admission and a scholarship, and Jason plans to completed the required work and attended. Subsequently, he attained a 3.8 average which puts him on the dean's list. The president assumed an aggressive advocate stance, advocating that he become a resident assistant in the dorms. Jason has visited the John Dewey Academy six times during the year because he wants to "give back" to the school which helped him mature. He has forgiven the president and now recognizes the confrontations were expressions of concern.
DiscussionIt is premature to know whether Jason will be a "success" or a "failure." Undeniably, Jason was helped by confrontation because he excelled and was admitted by a college of quality. How much has this adolescent grown, and what the quality of his interpersonal relationships will be, has not been determined. Judicious handling of this complicated situation has avoided the preclusion of future educational, professional, and social successes.
This kind of confrontation is justified when the adolescent remains intransigent or engages in extremely dangerous behavior. Alexander (1950) describes a patient who was irritating and engaged in regressive behavior. When the patient complained that no one liked him, rather than commiserating, Alexander opines that no one liked him because he was unpleasant. Subsequently the patient established a positive treatment alliance. Hearing the truth from a caring professional enabled the patient to trust and to move forward. Corwin (1991) labels this kind of intervention heroic: "When such statement is made, it is an emergency situation....The analyst knows it, the patient is...aware....But both know the moment it is uttered that it may have a prophetic significance for the patient....It implies that a psychic reaction must lead toward the establishment of a working alliance" (p. 83). We have utilized this sort of radical intervention for six seniors in past years, all of whom eventually returned to graduate. We believe Jason will not be an exception.
Critics contend that confrontation is controversial, counter therapeutic, and cruel punishment which often brutalizes persons-in-treatment. Confrontation attempts to modify irresponsible, impulsive, immature, stupid and self-destructive behavior. Confrontation penetrates denial, distortion, and dysfunctional attitudes. Critics protest, furthermore, that the use of confrontation is prompted by a negative countertransference reaction. Confrontation has been labeled "attack therapy" for pejorative reasons. Opponents of "attack therapy" do not under-stand is that confrontation has proven effective to eradicate malignant, dangerous, vicious attitudes and acts. While some critics condemn confrontation to be "cruel," they need to remember that Dewey students have engaged in dangerous, often death-defying behavior which demands heroic intervention. Unless the therapist can persuade the youth to avoid a collision course with disaster, there can be profoundly serious consequences. The primary goal of psychotherapy is to preserve life, so desperate and heroic treatment interventions are required for this difficult-to-treat population. When viewed from this humanistic perspective, confrontation connotes caring by the therapist who attempts to convince the adolescent to become more responsible, responsive, and respectful.
ConclusionWe have described a confrontation as a key aspect of a non-medically oriented residential therapeutic community. In our view, confrontation in the context of residential treatment is a potent psychotherapeutic tool that produces not only the acquisition of prosocial values but also behavioral improvement. Since these changes are internalized, long-term prognosis is quite good. Although we have no long-term systematic follow-up, anecdotal data confirm a less-than-ten-percent recidivism rate, which, to the best of our knowledge, is unmatched at any other residential treatment program. Bratter et al. (2006) contend "critics claim that confrontation psychotherapy is painful and simplistic. But they cannot explain how and why adolescents, who were extreme casualties, improve in a confrontational treatment milieu with escalating expectations for intellectual excellence and moral integrity [that] can be achieved without compromising one for the other" (p. 14). Confrontation as a psychotherapeutic technique has a long history in self-help therapeutic communities. In our experience, it can also be very effective in promoting change in adolescents who are resistant to other treatment approaches. Clearly, confrontation warrants further study.
References
Adler, G. (1985), Borderline Psychopathology and Its Treatment. New York: Jason Aronson.
Alexander, F. & French, T. (1946), Psychoanalytic Therapy. New York: Ronald Press.
Brager, G., (1965), The indigenous worker: A new approach to the social work technician. Social Work, 10: 33-40.
Bratter, T. E. (1972), Confrontation group psychotherapy with affluent, alienated drug abusing adolescents. Psychother.: Theory, Res. & Pract., 9: 308-313.
Bratter, T. E. (1977), Confrontation groups: The therapeutic community's gift to psychotherapy. In Proceedings of the First World Conference on Therapeutic Communities, ed. P. Vamos & J. J. Devlin. Montreal, Canada: Portage Press, pp. 164-174.
Bratter, T. E. (1978), The four 'Rs' of the American self-help therapeutic community: Rebirth, responsibility, reality and respect. In Proceedings of the Third World Conference on Therapeutic Communities, ed. J. Corelli, I. Bonfiglio, T. Pediconi, & M. Collumb. Rome: International Council of Alcoholism and Addictions Press, pp. 434-448.
Bratter, T. E., Collabolletta, E., Fossbender, A. J., Pennacchia, M. C, & Rubel, J. R. (1985), The American self-help residential therapeutic community: A pragmatic treatment approach for addicted character-disordered individuals. In Alcoholism and Substance Abuse: Strategies for Clinical Intervention, ed. T. E. Bratter & G. G. Forrest. New York: Free Press, pp. 461-507.
Bratter, T. E. (2003), Group psychotherapy with gifted, self-destructive, drug-dependent, unconvinced adolescents. Group, 27: 131-146.
Bratter, T. E., Bratter, C. J., Coiner, N. L., & Steiner, K. M. (2006), Motivating gifted, defiant, and unconvinced students to succeed at the John Dewey Academy. Ethical Human Psychology and Psychiatry, 8: 7-16.
Brook, W. (1996), Adolescents who abuse substances. In Group Therapy with Adolescents, ed. P. Kymissis & D. A. Halpern. Washington, DC: American Psychiatric Association, pp. 243-264.
Carkhuff, R. R. & Berenson, R. G. (1967), Beyond Counseling and Therapy. New York: Holt, Rinehart and Winston.
Casriel, D. (1963), So Fair a House: The Story of Synanon. Englewood Cliffs, NJ: Prentice-Hall.
Cohen, A. I., (1982), Confrontation Analysis: Theory and Practice. New York: Grune & Stratton.
Corwin, H. A. (1991), Therapeutic confrontation from routine to heroic. In Confrontation in Psychotherapy, eds. G. Adler & P. G. Myerson. Northvale, NJ: Jason Aronson. pp. 69-94.
Devereux, G. (1951), Some criteria for the timing of confrontations and interpretations. Intl. J. Psychoanal., 32:19-24.
Gans, J. S. & Weber, R. L. (2000), The detection of shame in group psychotherapy: Uncovering the hidden emotion. Intl. J. Group Psychother., 50:381-396.
Garner, H. H. (1970), Psychotherapy: Confrontation Problem-Solving Technique. St Louis: Warren H. Green.
Glaser, F. B. (1974), Some historical and theoretical background of a self-help addiction treatment program. Amer. J. Drug & Alcohol Abuse, 1:37-52.
Giovacchini, P. (1985), Countertransference and the severely disturbed adolescent. Adolescent Psychiatry, 12:449-467.
Hurvitz, N. (1970), Peer self-help groups and their implications for psychotherapy. Psychother. Theory, Prac. Res., 7:41-47.
Johnson, S. M. (1985), Characterological Transformation: The Hard Work Miracle. New York: Norton.
Kaufman, G. (1989), The Psychology of Shame: Theory and Treatment of Shame-Based Syndromes. New York: Springer.
Maslow, A. H. (1967), Synanon and eupsychia. J. Humanistic Psychol., VII:21-32.
Meeks, J. E. & Bernet, W. (1990), The Fragile Alliance: An Orientation to the Psychiatric Treatment of the Adolescent. Malabar, FL: Krieger Publishing.
Nunberg, H. (1955), Principles of Psychoanalysis. New York: International Universities.
Reisman, F. (1965), The "helper" therapy principle. Social Work, 10:27-32.
Ruitenbeek, H. (1970), The New Group Therapies. New York: Avon Books.
Shankman, S. (1978), Criteria and factors affecting admission into and completion of the therapeutic community program. In Proceedings of the Third World Conference on Therapeutic Communities, ed. J. Corelli, T. Bonfiglio, T. Pediconi, & M. Collumb. Rome: Centro Italiano di Solidarieta, pp. 156-160.
Sugarman, B. (1974), Daytop Village: A Therapeutic Community. New York: Holt, Rinehart, and Winston.
Sugarman, B. (1986), Structure, variations, and context: A sociological view of the therapeutic community. In Therapeutic Communities for Addictions: Readings in Theory, Research and Practice, ed. G. De Leon & J. T. Ziegenfuss. Springfield, IL: Charles C. Thomas, pp. 65-82.
Van Stone, W. W. & Gilbert, R. (1972), Peer confrontation groups: What, why, and whether. Amer. J. Psychiat., 129:581-591.
Volkman, R. & Cressey, D. R., (1963), Differential association and the rehabilitation of drug addicts. Amer. J. Soc., 69:131-141.
Yablonsky, L. (1965), The Tunnel Back: Synanon. New York: Macmillan.
Thomas Edward Bratter is President and Founder of The John Dewey Academy in Great Barrington, Massachusetts.
Lisa Sinsheimer, M.D. is a psychiatric consultant and Admissions Coordinator at The John Dewey Academy in Great Barrington, Massachusetts.
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