August Aichorn, Bruno Bettelheim, Fritz Redl and David Wineman were among the
early pioneers in using Milieu Therapy.
A type of treatment in which the patient's social environment is manipulated
for his benefit.
Therapeutic community, in which patients stay at
a residence where they lead a highly structured life. This approach can be used for substance abusers, or people with
severe disorders that impair their ability to function in normal living.
The goal for the therapist is to translate his or her psychodynamic understanding
and emotional experience of the client and the team into clinical interventions that have a practical, positive and measurable
effect on the client's ability to plan and pursue his or her life.
In all of their work with clients, milieu therapists draw upon a psychodynamic
understanding of client experience and behavior. For example, in response to a client who is persistently disruptive in therapy
groups, the milieu therapist might offer an interpretation, set a limit or ask the client to leave, encourage other group
members to give the client feedback on the effect of the behavior on the group, and/or call upon the rest of the staff to
consider what is being expressed for the client group through this behavior. Similarly, when a client refuses to apply for
a job, after agreeing to do so as part of his or her treatment plan, the milieu therapist must determine the most effective
In the work of case management, milieu therapists encourage clients to practice
new ways of engaging with others and the world. Essentially, the clinician consults to the client's project of pursuing treatment
and life. For example, Sarah joined our program in the throes of an extended psychotic episode. In the early stages of her
treatment, her milieu work focused on managing her medication, preparing to join a client household and making a commitment
to a sobriety management program. Later, she emphasized learning to communicate with housemates, friends, family and others
in ways that built relationships, rather than creating havoc. In the final months of her treatment, she worked with her milieu
therapist to develop and execute a plan for the next stage in her life including a living situation, a social network, a vocation
and ongoing support.
Milieu therapists also help clients to recognize existing ego resources and then
to expand and strengthen them. A client who copes with stress by cutting herself would work to identify and use alternative
means for managing distressing feelings. The clinician would also help her to develop a strategy for her life that would help
her to modify or avoid overwhelming situations and seek out more positive experiences.
In working in their role as team members, milieu therapists contribute to the
team's overall understanding of, and approach to working with, the individual client and the client community. They work with
the team to share, understand, and contain the difficult emotional experiences of the team's clinical work. This occurs within
the context of the supervisory and team settings: individual supervision (managerial and clinical), milieu team meetings,
milieu consultation group, treatment team meetings, and the staff group as a whole.
The Methods of Milieu