Milieu Therapy: Background, Uses, and Effectiveness

What Is Milieu Therapy?

The term “milieu” refers to a setting or environment; milieu therapy is a type of psychotherapy that involves forming therapeutic communities among groups of clients who meet for treatment sessions.^4,5 It is at times used interchangeably with the terms “therapeutic community,” “optimal healing environment,” and “therapeutic milieu.” Milieu therapy takes place in various contexts, including psychiatric nursing, substance abuse treatment, community mental health practice, residential treatment, and inpatient psychiatry.

Milieu therapy involves creating a safe, nonthreatening setting to help participants feel more comfortable expressing themselves. When clients socialize with one another and their therapist in the group setting, they can immediately receive feedback to positively influence the course of their treatment.¹ The therapist creates and encourages this environment so that the client can begin to become more comfortable with and incorporate these healthy experiences, helping to strengthen their mental health. Maintaining the boundaries of an environment provides the stability people need to feel comfortable engaging with others and reducing maladaptive behaviors.⁶

This method deconstructs the hierarchical nature of many therapeutic environments.⁵ A mutual respect among clients and health care staff is integral to allow shared authority instead of authority resting with the therapist. The participants hold responsibility for their behavior. Rather than encouraging dependence on mental health counselors and staff, milieu therapy focuses on the environment and the community.⁶ Some milieu therapy programs use interdisciplinary treatment teams from several psychology and health care fields. Therapists who use milieu therapy might also combine it with psychotherapeutic interventions like cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) to treat clients.^7,8 This helps to provide a variety of different perspectives to the clients.

Milieu therapy takes place in various contexts, including psychiatric nursing, substance abuse treatment, community mental health practice, residential treatment, and inpatient psychiatry.

What Is the History of Milieu Therapy?

Milieu therapy as it exists today first emerged in Eastern Europe in inpatient psychiatric settings during the early part of the 20th century.³ However, the principles of milieu therapy are visible in ideologies and progress in psychotherapy dating back over two centuries.

In the late 1700s, Philippe Pinel, a French physician and psychiatrist, created moral therapy, a precursor to milieu therapy. He released patients in a French asylum from the chains in which they were held.⁹ By providing more humane treatment, Pinel revolutionized how psychiatric patients were treated while institutionalized.¹⁰

In the twentieth century, psychoanalyst August Aichhorn worked with children and their environments. His work informed that of psychoanalyst Fritz Redl and psychologist Bruno Bettelheim in the 1950s; they also worked with children and were the first to use the term “milieu therapy.” Bettelheim is credited with transforming group care for children in the United States. He posited that children’s surroundings could be manipulated to foster affective and behavioral changes. His Orthogenic School became an example of a successful therapeutic environment, encouraging healthy identity and functioning in children.³

Milieu therapy is at times used interchangeably with the terms “therapeutic community,” “optimal healing environment,” and “therapeutic milieu.”

How Does Milieu Therapy Work?

Milieu therapy posits that a therapeutic environment is an integral part of the therapeutic process and necessary for change. While it can involve different types of traditionally structured therapies like group therapy, family therapy, and individual therapy, it is not a specific, structured intervention on its own. Practitioners and experts in the field instead see milieu therapy as a collection of beliefs informed by the needs and abilities of the community, clients, and staff. It requires a perspective that acknowledges the constant, ongoing nature of the treatment, as it is not defined by start or end dates or individual moments.³

Milieu therapy harnesses several facets of the environment and treatment perspective. It first establishes that an environment is structured, safe, secure, and comfortable.⁷ The therapists have complete control of the environment, so they can optimize it to promote desired positive changes. Every part of the therapeutic environment is regulated.

In inpatient environments, the mental health team considers everything from the time clients wake up in the morning to room decorations and makes each decision based on how it might affect clients’ behavior.³ Therapists also use the necessary daily living activities to facilitate change.

Group dynamics are important factors in encouraging behavioral change and healthy communication by increasing individual participants’ awareness of how their actions impact others. When conflicts arise, the therapists provide opportunities for clients to learn new coping mechanisms to deal with stressors more positively. For instance, therapists often see mealtimes as opportunities for the clients to act out the strategies they’ve learned. When one person is being hurtful or harmful to the others, rather than stepping in, the therapists encourage the clients to communicate kindly, directly, and effectively to work out the issue or dispute. Additionally, they let the social environment spur the clients to correct their maladaptive behaviors. Where other methodologies might punish or limit negative behaviors or selectively reinforce desired actions, milieu therapy lets the community encourage healthy behaviors and actions.³

The therapeutic milieu also represents a safe environment in which “real-world” scenarios can occur and play out, so that clients learn how to handle social interactions and conflicts that would have been overwhelming in a less consistent environment. The environment encourages this by providing a “lounge” or other areas where clients can chat, participate in informal groups, and play games. The competitive nature of a game can be a helpful, low-stakes setting to work through differences. One of the functions of the milieu is to help clients transfer their coping skills to social settings outside of the therapeutic environment.³

Conditions Commonly Treated by Milieu Therapy

Milieu therapy is used in various clinical settings and can help treat many different maladaptive behaviors and mental health issues. Conditions that might benefit from milieu therapy include:

• drug and alcohol abuse and addiction³
• behavior disorders³
• posttraumatic stress disorder (PTSD)³
• schizophrenia²

In addition to treating the above conditions, milieu therapy can also reduce incarceration recidivism.⁵

The Potential Benefits and Scientific Effectiveness of Milieu Therapy

As a method for delivering treatment, milieu therapy provides the following potential benefits:³

• a supportive environment that helps to foster positive behavior and the acquisition of new coping skills
• a sense of safety
• the ability to receive immediate feedback to encourage progress
• greater self-awareness and self-confidence
• improved ability to manage stressors
• improved communication skills

Numerous studies have established the effectiveness of milieu therapy. A 2013 qualitative study authored by researchers from the VID Specialized University in Stavanger, Norway, examined cognitive milieu therapy using an interdisciplinary team. They applied cognitive milieu therapy with participants with dual diagnoses of mental health disorders and substance abuse disorders. Based on individual, qualitative interviews, the research team found that the participants showed significant improvement in their ability to learn new skills.¹¹

Milieu therapy has also shown effectiveness in improving the quality of life among geriatric clients. In 2021, researchers from the Odessa National Medical University in Odessa, Ukraine, used milieu therapy with elderly residents in nursing home settings. They found that the intervention helped facilitate more involvement in social activities, reduced the prevalence of somatic issues and psychosomatic conditions, and improved problem-solving skills.¹²

A 2020 study conducted by researchers from various institutions in India evaluated the effectiveness of milieu therapy for people with schizophrenia in an inpatient setting. The researchers gave half of the participants milieu therapy in addition to the routine hospital treatment, while the other group only received the latter. Through the patient-staff conflict checklist shift report and other observational methods, the researchers found that the participants who received milieu therapy showed greater reductions in self-harm, aggression, and rule-breaking than the control group.¹³

Summary/Outlook

Milieu therapy has shown benefits for people with a wide variety of mental health and behavioral disorders and is widely used in group counseling for various demographics. This method uniquely harnesses the environment for therapeutic engagement that extends beyond the scope of an individual therapy session.