Issues in milieu treatment

Abstract

Milieu treatment is discussed as a set of considerations in the creation and operation of mental health settings that care for patients on a more than out patient basis. Considerable experience has been gained in the application of milieu techniques in the past 25 yr. At the same time, the variety and tasks of milieus have increased and become more complex. This is particularly true for the schizophrenic range of disorders, where the problems encountered may range from management of acute symptomatology to rehabilitation of the chronically institutionalized. The practitioner of milieu treatment must provide for both the individual and the organization. The best planned program cannot succeed with poor staff morale or a hostile patient group. Thus the leaders of such units must be sensitive to phenomena of the institution's social system as much as to individual pathology and dynamics. The resources and limitations of the program's mandate, the strengths and weaknesses of staff, the ebb and flow of social dynamics in complex organizations, the qualities and needs of the patient population, all require careful attention for an effective milieu. The author reviews specific aspects of milieu programs (group therapy, community meetings, patient government, team treatment) to consider their place in a wider program. The milieu management of problems frequently encountered in schizophrenia is also considered briefly. He argues that the best specific program for a given milieu is usually devised by the staff who will implement it. Attention to daily events and planning, which are referred to generally as 'management', is more critical than the arbitrary use of particular techniques of therapy. This emphasis corresponds with the importance of developing ego skills and enhancing adaptive qualities in schizophrenic individuals. Similarly, in implementing therapeutic community the author lists a set of general therapeutic processes that facilitate the engagement and change of the individual patient, as well as processes important in maintaining the community as a whole.