Milieu work has its primary roots in the therapeutic community movement, which emphasized the role of social and societal relationships in developing, maintaining and ameliorating mental illness and its symptoms. Malcolm Pines, in his paper Forgotten Pioneers: The unwritten history of the therapeutic community movement (Therapeutic Communities, 20:1, 1999), traces the 20th century, pre-WWII development of milieu therapy. During this period, diverse practitioners began to apply Freuds insights into intrapsychic life to the group and social arenas, and extend the thinking and understanding of the role of the community in the life of the individual.

David Kennard, in his book An Introduction To Therapeutic Communities (Jessica Kingsley Publishers, 1998, London), picks up the story as the pioneering work of Wilfred Bion and others in rehabilitating traumatized war victims initiated dramatic developments in this approach to treating mental illness. Development continued with the evolution of therapeutic community treatment for individuals with a broader range of psychiatric diagnoses, including severe personality disorders, psychotic disorders and substance abuse.

The therapeutic community movement and milieu therapy share several common values and beliefs. First is that the clients difficulties are both expressed in, and arise in, relationships with other people. The milieu allows for highly sensitive and attuned understanding of how a clients relationships are derailed. It is also the arena where the client is offered many opportunities to find better ways of relating.

A second belief is that therapy is essentially a learning process that involves both clients and staff. To be effective in the milieu, the therapist must be available to be affected and changed by his or her interactions with the client. This self-reflective teaching model rests on the understanding that clients and staff share the same psychological processes, while recognizing the difference in the roles they play in the clinical situation.

The Methods of the Milieu:

The milieu therapist program plays a central role in the treatment of the client. The therapist meets the client in the client's home, in a consulting room, at the beach during a client outing, in the hospital during an acute episode, in the hallway, the parking lot and pretty much anywhere in between. The milieu is where the concepts and insights of the "in-office" therapies meet the reality of the client's daily 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 intervention.

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.

In all of these settings, the milieu therapist is working 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.

There are a variety of treatment modalities or forms available to meet each patient's individual needs. The modality chosen will depend on factors such as diagnosis, age of the patient, family support,  financial constraints and patient preference. 

Individual Psychotherapy is the modality with one patient and one therapist. This form offers the most attention to the patients individual concerns however it can be limited in that it cannot directly study family or social relationships. There are many different styles or theoretical orientations of therapists such as psychodynamic, cognitive and behavioral.

Family Psychotherapy is conducted with all or as many members as possible of a family. The work may all be done with the entire group or involve various combinations of family members. The process helps identify and modify maladaptive or destructive interaction patterns as well as foster group communication and problem solving skills.

Group Psychotherapy....... is conducted with at least three and up to fifteen patients together. This modality offers the patient the opportunity to interact with others and learn from them as well as study their own relationship style. Patients usually encounter some social anxiety in beginning group therapy, however it offers an ideal environment in which to challenge such anxieties.

Homogeneous groups are made up of individuals with similar concerns such as chemical dependency or women's issues. These groups offer support and understanding and the feeling that one is not the only one struggling with a given set of concerns.

Heterogeneous groups have a more varied membership and more closely approximate the world at large.

Stress Management training is a process of identifying stressors, learning ones physiological and cognitive responses to stress and developing techniques to manage those responses. Common stress management techniques are systematic desensitization, relaxation training, and cognitive therapy.

Medication Management is the use of psychotropic medications to manage emotional, cognitive, and behavioral symptoms. The medication is prescribed by psychiatrists after thorough evaluation and with ongoing monitoring. Medication management is usually implemented in conjunction with other therapies aimed at treating the underlying causes of the condition

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3) TOPIC:  AGORAPHOBIA.

What is agoraphobia?

Agoraphobia is the fear of being in a situation where one might experience anxiety or panic and where escape from the situation might be difficult or embarrassing. People with agoraphobia may feel anxious about such things as loss of bladder or bowel control or choking on food in the presence of others. They also might feel anxious about being home alone, leaving home, or being in a crowded place, such as on public transportation or in an elevator, where it might be difficult or embarrassing to find a way out. To avoid the anxiety associated with these situations they refrain from putting themselves into such situations.

The severity of agoraphobia is quite variable. Some people with agoraphobia live essentially normal lives as they avoid potentially anxiety-provoking situations. However, in severe cases of agoraphobia, people are homebound. These people work very hard to avoid any and all situations that might cause them to become anxious.

What characteristics are associated with agoraphobia?

Two major characteristics are associated with agoraphobia:

1. People develop anxiety when thinking about being in a situation out of their comfort zone. They fear feeling trapped in a situation where they judge it would be difficult or embarrassing for them to leave the situation.
2. People avoid those situations which bring them anxiety or panic. It is the fear of the anxiety that leads to the agoraphobia.

Does agoraphobia affect males, females or both?

About twice as many women than men report that they experience agoraphobia. Frequently, people report that the onset of their agoraphobia followed a stressful or traumatic event in their lives.

At what age does agoraphobia begin?

The most common age for agoraphobia to begin is when a person is in his/her mid to late 20s.

How often is agoraphobia seen in our society?

Less than one percent (1%) of the population of the United States is thought to have agoraphobia.

How is agoraphobia diagnosed?

People suffering from agoraphobia sometimes fear that they are "losing" their mind or "going crazy" because of their fears and anxiety. Consequently, they might seek advice from a mental health professional.

Also, it is common for a friend or family member to notice that another person is reluctant to leave home without a companion. For instance, a spouse might notice that his/her mate finds reasons not to leave home. In these cases, the friend or family member often urges the agoraphobic to seek professional help.

A mental health professional arrives at the diagnosis of agoraphobia by taking a careful personal history from the client/patient. There are no laboratory tests required to confirm a diagnosis of agoraphobia nor are there any physical conditions that must be met. However, it is very important for the therapist not to overlook a physical illness that might mimic or contribute to a psychological disorder. If there is any doubt about a medical problem, the mental health professional should refer to a physician who will perform a complete physical examination and request any necessary laboratory tests.

Countinue........

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The Clinical Milieu