Milieu therapy, also known as therapeutic community, involves structuring a client's environment and interactions to promote behavioral change and improve psychological health. It operates under several assumptions, including that every interaction is an opportunity for therapy, clients own their behavior and environment, and peer pressure can be a useful tool when managed constructively. An interdisciplinary treatment team oversees each client's individualized treatment plan and works to fulfill responsibilities in areas like psychiatry, psychology, nursing, social work, therapy, and spiritual care. The goal is to address all of a client's needs through a supportive community environment.

1. MILIEU THERAPY—THE
THERAPEUTIC COMMUNITY

2. • The word milieu is French for “middle.” The English translation of the
word is “surroundings, or environment.” In psychiatry, therapy
involving the milieu, or environment, may be called milieu therapy,
therapeutic community, or therapeutic environment.
Therefore, Milieu therapy can be defined as, A scientific structuring
of the environment in order to effect behavioral changes and to
improve the psychological health and functioning of the individual
(Skinner, 1979).
• The goal of milieu therapy is to manipulate the environment so that
all aspects of the client’s hospital experience are considered
therapeutic.

3. BASIC ASSUMPTIONS
• Skinner (1979) outlined seven basic assumptions on which a
therapeutic community is based:
• 1. The health in each individual is to be realized and encouraged to
grow. All individuals are considered to have strengths as well as
limitations. These healthy aspects of the individual are identified and
serve as a foundation for growth in the personality and in the ability
to function more adaptively and productively in all aspects of life.

4. • 2. Every interaction is an opportunity for therapeutic intervention.
Within this structured setting, it is virtually impossible to avoid
interpersonal interaction. The ideal situation exists for clients to
improve communication and relationship development skills.
Learning occurs from immediate feedback of personal perceptions.
• 3. The client owns his or her own environment. Clients make
decisions and solve problems related to government of the unit. In
this way, personal needs for autonomy as well as needs that pertain
to the group as a whole are fulfilled.

5. • 4. Each client owns his or her behavior. Each individual within the
therapeutic community is expected to take responsibility for his or
her own behavior.
• 5. Peer pressure is a useful and a powerful tool. Behavioral group
norms are established through peer pressure. Feedback is direct and
frequent, so that behaving in a manner acceptable to the other
members of the community becomes essential.

6. • 6. Inappropriate behaviors are dealt with as they occur. Individuals
examine the significance of their behavior, look at how it affects other
people, and discuss more appropriate ways of behaving in certain
situations.
• 7. Restrictions and punishment are to be avoided. Destructive
behaviors can usually be controlled with group discussion. However, if
an individual requires external controls, temporary isolation is
preferred over lengthy restriction or other harsh punishment.

7. CONDITIONS THAT PROMOTE A THERAPEUTIC
COMMUNITY
• In a therapeutic community setting, everything that happens to the
client, or within the client’s environment, is considered to be part of
the treatment program. The community setting is the foundation for
the program of treatment
• Under what conditions, then, is a hospital environment considered
therapeutic? A number of criteria have been identified:

8. • 1. Basic physiological needs are fulfilled. As Maslow (1968) has
suggested, individuals do not move to higher levels of functioning
until the basic biological needs for food, water, air, sleep, exercise,
elimination, shelter, and sexual expression have been met.
• 2. The physical facilities are conducive to achievement of the goals
of therapy. Space is provided so that each client has sufficient privacy,
as well as physical space, for therapeutic interaction with others.
Furnishings are arranged to present a homelike atmosphere—usually
in spaces that accommodate communal living, dining, and activity
areas—for facilitation of interpersonal interaction and
communication.

9. • 3. A democratic form of self-government exists. In the therapeutic
community, clients participate in the decision making and problem solving
that affect the management of the treatment setting. This is accomplished
through regularly scheduled community meetings.
• These meetings are attended by staff and clients, and all individuals have
equal input into the discussions.
• 4. Responsibilities are assigned according to client capabilities. Increasing
self-esteem is an ultimate goal of the therapeutic community. Therefore, a
client should not be set up for failure by being assigned a responsibility
that is beyond his or her level of ability. By assigning clients responsibilities
that promote achievement, self-esteem is enhanced. Consideration must
also be given to times during which the client will show some regression in
the treatment regimen. Adjustments in assignments should be made in a
way that preserves self-esteem and provides for progression to greater
degrees of responsibility as the client returns to previous level of
functioning.

10. • 5. A structured program of social and work-related activities is
scheduled as part of the treatment program. Each client’s
therapeutic program consists of group activities in which
interpersonal interaction and communication with other individuals
are emphasized. Time is also devoted to personal problems.Various
group activities may be selected for clients with specific needs .
A structured schedule of activities is the major focus of a therapeutic
community. Through these activities, change in the client’s
personality and behavior can be achieved. New coping strategies are
learned and social skills are developed. In the group situation, the
client is able to practice what he or she has learned to prepare for
transition to the general community.

11. • 6. Community and family are included in the program of therapy in an
effort to facilitate discharge from treatment. An attempt is made to
include family members, as well as certain aspects of the community that
affect the client, in the treatment program. It is important to keep as many
links to the client’s life outside of therapy as possible .Family members are
invited to participate in specific therapy groups and, in some instances, to
share meals with the client in the communal dining room.
• Connection with community life may be maintained through client group
activities, such as shopping, picnicking, attending movies, and visiting the
zoo. These connections with family and community facilitate the discharge
process and may help to prevent the client from becoming too dependent
on the therapy.
•

12. • The following are responsibilities of IDT team members.
• Psychiatrist
Serves as the leader of the team. Responsible for diagnosis and treatment
of mental disorders. Performs psychotherapy; prescribes medication and
other somatic therapies.
• Clinical psychologist
• Conducts individual, group, and family therapy.Administers, interprets, and
evaluates psychological tests that assist in the diagnostic process.
• Psychiatric clinical nurse Specialist
• Conducts individual, group, and family therapy.Presents educational
programs for nursing staff. Provides consultation services to nurses who
require assistance in the planning and implementation of care for
individual clients.

13. THE PROGRAM OF THERAPEUTIC COMMUNITY
•
• Care for clients in the therapeutic community is directed by an interdisciplinary
treatment (IDT) team.
An initialassessment is made by the admitting psychiatrist, nurse, or other
designated admitting agent who establishes a priority of care.
The IDT team determines a comprehensive treatment plan and goals of therapy
and assigns intervention responsibilities. All members sign the treatment plan
and meet regularly to update the plan as needed. Depending on the size of the
treatment facility and scope of the therapy program, members representing a
variety of disciplines may participate in the promotion of a therapeutic
community.
For example, an IDT team may include a psychiatrist, clinical psychologist,
psychiatric clinical nurse specialist, psychiatric nurse, mental health technician,
psychiatric social worker, occupational therapist, recreational therapist, art
therapist, music therapist, psychodramatist, dietitian, and chaplain.

14. • Psychiatric nurse Provides ongoing assessment of client condition, both
• mentally and physically. Manages the therapeutic milieu on a 24-hour basis.Administers
medications. Assists clients with all therapeutic activities as required. Focus is on one-to-
one relationship development.
• Mental health technician
Functions under the supervision of the psychiatric nurse. Provides assistance to clients in
the fulfillment of their activities of daily living. Assists activity therapists as required in
conducting their groups. May also participate in one-to-one relationship development.
• Psychiatric social worker
• Conducts individual, group, and family therapy. Is
• concerned with client’s social needs, such as placement, financial support, and
community requirements. Conducts in-depth psychosocial history on which the needs
assessment is based. Works with client and family to ensure that requirements for
discharge are fulfilled and needs can be met by appropriate community resources.

15. • Occupational therapist
• Works with clients to help develop (or redevelop) independence in performance of
activities of daily living. Focus is on rehabilitation and vocational training in which clients
learn to be productive, thereby enhancing self-esteem. Creative activities and
therapeutic relationship skills are used.
• Recreational therapist
• Uses recreational activities to promote clients to redirect their thinking or to rechannel
destructive energy in an appropriate manner. Clients learn skills that can be used during
leisure time and during times of stress following discharge from treatment. Examples
include bowling, volleyball, exercises, and jogging. Some programs include activities such
as picnics, swimming, and even group attendance at the state fair when it is in session.
• Music therapist
• Encourages clients in self-expression through music. Clients listen to music, play
instruments, sing, dance, and compose songs that help them get in touch with feelings
and emotions that they may not be able to experience in any other way.

16. • Art therapist
• Uses the client’s creative abilities to encourage expression of emotions and feelings through artwork. Helps
clients to analyze their own work in an effort to recognize and resolve underlying conflict.
• Psychodramatist
• Directs clients in the creation of a “drama” that portrays real-life situations. Individuals select problems they
wish to enact, and other clients play the roles of significant others in the situations. Some clients are able to
“act out” problems that they are unable to work through in a more traditional manner. All members benefit
through intensive discussion that follows.
• Dietitian
• Plans nutritious meals for all clients. Works on consulting basis for clients with specific eating disorders, such
as anorexia nervosa, bulimia nervosa, obesity, & pica.
• Chaplain
• Assesses, identifies, and attends to the spiritual needs of clients and their family members. Provides spiritual
support and comfort as requested by client or family.
• May provide counseling if educational background includes this type of preparation.
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