In contrast to the artificially determined limitations imposed by managed behavioral health networks, thorough treatment planning with very disturbed children and adolescents entails sustained assessment and recognizing that symptoms are multidimensional expressions of diverse, interacting developmental pathways. Meaningful psychotherapy with psychotic children and adolescents has to be guided by the individual patient's idiosyncratic characteristics and vulnerabilities across domains of functioning. Comprehensive treatment for youth with psychotic features requires flexibility about the need for long-term psychotherapy, openness to the value of integrating psychoanalytic formulations and cognitive behavioral strategies, and an appreciation of the primacy of the psychotherapeutic relationship.