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issues in milieu treatment

Richard Almond

By "milieu treatment" we refer to various aspects inthe organization of a total treatment system that canfacilitate improvement of patients.1 When we practicemilieu treatment, we "treat" the organization as much asthe individual. An understanding of this prevents themistaken view of milieu treatment as an alternativeapproach to mental illness, competitive with somatictreatments or psychotherapies. A number of seriousresearch studies have approached milieu treatment in thissimplistic way; the result has been its debunking as atreatment for schizophrenia in comparison, for example,to treatment with phenothiazine drugs alone (May 1968).The issues are far more three-dimensional in the actualtreatment settings where we try to help patients with thebest available resources, be they pharmacologic, psycho-therapeutic, or organizational. To understand the place ofmilieu treatment in such comprehensive situations, wemust consider a myriad of interacting factors: othertherapies, including drugs; program size; makeup of thepatient population and the staff; relation of the treatmentsetting to the wider environment; timing of a patient'sadmission in relation to his "career" (i.e., personal historyof deviant behavior and its treatment); and his length ofstay.

•Reprint requests should be addressed to the author at TheCollective Psychotherapy Center, 4222 El Camino Real, PaloAlto, Calif. 94306.

11 have chosen to refer to persons receiving care in institutionsas "patients," since the majority of inpatient care continues tobe in hospital settings. In other settings, the appropriate desig-nation might be "client," "resident," or "member." While"patient" has negative connotations to some, it remains themost generally recognized term and is probably preferable to theuse of a diagnostic label.

Instead of trying to propose one "way" to "do " milieutreatment, I shall discuss a number of salient issues likethose above. In doing so I hope to convey my convictionthat milieu treatment, especially for schizophrenic pa-tients, is an extremely complex, varied endeavor that weare only beginning to understand clearly. The faddishimpatience of our modern technological era may beleading to a rejection of milieu treatment before itsapplication has been fully understood. The 19th centurydecline of moral treatment—apparently a highly effectivetechnique-is a warning to us to understand and apply themilieu techniques developed in the past 25 years beforewe are swept off in new directions.

No one program description would be adequate tocover the variety of settings now existing. Each issue to bediscussed involves one aspect of the complex interrela-tions that, overall, comprise milieu treatment:

• Management;• Medication and milieu;• Patient careers;• The "milieu of the milieu";• Therapeutic community—including therapeutic pro-

cess, charisma and communitas, and authority andnurture;

•Specific problems in working with schizophrenics inmilieu treatment;

• Specific format and activities used in milieu treat-ment;

• Application of milieu treatment.

"Milieu treatment" or "milieu therapy" is often usedinterchangeably with "therapeutic community." Althoughin many settings there is reason for the use of both terms,they relate to two different levels of treatment. Milieu

ISSUE NO. 13, SUMMER 1975 13

therapy refers to the use of the total milieu—formaltreatment program, staff reactions, special activities, peerrelations-in the overall treatment program of the indivi-dual patient. Therapeutic community refers to an en-hancement of the treatment organization through en-couraging its development as a cohesive social group. Likemilieu treatment, the term therapeutic community isfrequently misunderstood. It is often misinterpreted tomean a permissive, roleless, egalitarian brotherhoodamong sufferers and helpers. Properly conceived, thera-peutic community may in fact aspire toward a communalideal. But its therapeutic quality is crucially dependentupon its attention to detail and process, whether in thesharing of power with patients or in the day-to-dayprogress of any particular individual. Thus, I will bediscussing therapeutic community in a later section as oneimportant facet of milieu treatment.

Milieu techniques and treatment programs have notusually been developed for schizophrenics alone, except inchronic wards and some specialized research designs orprograms. Therefore, many of the comments here aboutprogrammatic aspects of milieu treatment are not limitedto this diagnostic group. Since schizophrenia may be acluster of disorders with certain common features, thislack of specificity is not a major problem. Further, majoracknowledged differences in the institutional experienceof individuals have led to the designation of at least threecategories of patients-acute, chronic, and recurring—witha functional significance for milieu treatment that is mostlikely far greater than diagnosis alone.

The single factor that influences milieu treatment mostprofoundly is length of stay. In the implementation of amilieu program, this consideration affects every otherissue in some way. The role of the milieu in a patient'stotal experience, and the effect of the individual's stay onthe total milieu, determine how intimately these effectscan, and should, become interwoven. Specifically, anytreatment technique that requires a committed involve-ment on the part of both patient and staff—individualpsychotherapy, therapeutic community, token econ-omy—must have time for an interaction to develop. Theshorter this time, the more limited will be the involvementand, necessarily, the more one-sided the approach.

A Core Issue: Management

Once hospitalization, or placement in some kind ofprogram beyond outpatient care has occurred, "admin-

istrative" or "management" issues become central totreatment. This is not to ignore the importance ofintrapsychic, interpersonal, or biological factors, but all ofthese are inevitably played out around the individual'sstatus as a patient (Goffman 1961). Admission to atreatment program implies that family, community, andoutpatient resources have not been sufficient to deal withthe behavior and/or subjective state of the disturbedindividual. In the process of admission, the institutioninevitably accepts a degree of control and authority overthe patient. Likewise the patient, directly or tacitly,expects the institution to exert controls and guide aspectsof his behavior. The way in which authority is handled bystaff, and the way in which power and responsibility aregradually returned to the patient, are important elementsin milieu treatment.

In milieu treatment, the focus on management as thecore of the organization has a number of importantfunctional implications. It means that: 1) The patient andall staff members are involved on a daily basis with therelevant issues; 2) there is no special, abstruse expertiseconnected with management that gives any one subgroupa special, exclusive role in treatment; 3) the importantsociological concomitants of institutional treatment-labeling of the patient as a deviant, his adoption of a"sick" role-can be dealt with head-on; and 4) inappropri-ate controls and restrictions are less likely to occur. I shalldiscuss each of these aspects of management in turn.

Universal Involvement inManagement Issues

A criticism of various forms of "medical model"treatment—custodial, pharmacological, or psychother-apeutic-is that decisions about a patient are made bythose least directly placed to observe or experience theeffects. In such settings decisionmaking becomes a com-plex, subtle business, with the less powerful groups(patients, aides, nurses) influencing decisions throughdeliberate, selective presentation of information tohigher-ups (Braginsky, Braginsky, and Ring 1969 andDunham and Weinberg 1960). When management issuesare dealt with more openly, such deceptions become lessnecessary. Power distribution may not change, but itbecomes difficult to ignore the fact that patients and aideshave better information about patients' behavior andfeelings than busy nurses, physicians, and specializedtherapists. Acknowledgment of the greater information


available to aides and patients often leads to sharingpower with them more explicitly. For example, inbehavior modification programs (which tend to maketraditionally implicit patterns explicit), aides are usuallybehavior observers and thus are recognized as the sourceof crucial information about target behaviors and rein-forcements. Through having his important role in the be-havior therapy system recognized, the aide becomes alegitimate member of the therapeutic team. Interestingly,many therapeutic units are then able to free aides formore long-range activities (such as planning, placement,and aftercare) because their behavior-monitoring func-tions have become more focused (Almond 1974a).

Similar observations can be made about patients intherapeutic communities who assume certain traditionalstaff roles: "specialing" other patients, leading meetings,observing and reporting behavior. Again, there is a doublegain: Patients not only supplement nursing staff butdemonstrate that they are not limited to the role of being"sick." This also provides modeling for newer patients.This pattern of "role paralleling" will be discussed laterin more detail.

Management-as-Therapy vs. "Therapist-A dministrator Split"

The separate operation of "therapy" on one hand and"administration" on the other has tended to confuse bothpatients and staff, and has usually led to a conflictresulting in a loss of dignity—and efficacy—for both. Thishas been best documented for psychoanalytically orientedinstitutions, but also holds true where family therapy orgroup therapies are emphasized, and is certainly true intreatment units emphasizing pharmacotherapy. When onepart of the staff feels excluded and disparaged by another,it is far more likely to carry this status difference into itsrelations with the patients. But if the philosophy of thetreatment program puts first emphasis on management,such divisions are less likely. The psychotherapist takes hisplace as an expert on conceptualizing one aspect of thepatient's hospital experience, just as the aide is an experton the patient's daily behavior outside of "therapy"meetings. Within this perspective of management, eachstaff group has its unique and equally legitimate place inthe organization, in its own eyes, and in its relation to thepatients.

The value of this role-legitimizing is not its democratic,equalitarian, leveling effect. Its real value lies in making

interactions of patients with staff as therapeutic aspossible. Only to the degree that the lowest ranked levelof staff feel like therapists (in the broad sense of having asignificant part in changing the patient's behavior) willthey be able to act and influence therapeutically.Further, in therapeutic communities where patients cometo take on certain responsibilities and powers usuallyaccorded staff, this legitimatization will be critical, as Ishall explain later.

Delabeling and Relabeling

One argument frequently raised against all institutionaltreatment is that the fact of hospital admission tends tofix the troubled person in a "sick" role, as embodied in adiagnostic label. Empirically, this criticism tends to betrue, at least as we measure the effects of labeling in termsof readmissions (i.e., if admission can be aborted, furtheradmissions are less likely). Whether avoiding admissionmakes for better individual functioning, or less overallsocietal burden is not yet known. Certainly, recentmassive closings of some State hospitals have only shiftedthe location of these labeling processes, transferring thechronic and semichronic patients, with their marginallifestyles, to the streets and the transient hotels of localcommunities.

Those working in a hospital setting should not ignorethe fact that hospitalization in itself has powerful effectson self-concept, on the attitudes of family and com-munity, and on the expectations of both sides. By givingmanagement a major focus, it is possible to diminish thenatural tendency toward labeling. Efforts can be made toencourage the patient to maximize the continuity ofactivities that are important to his self-esteem andplace in the community, such as work and family life.Likewise, staff can work with family members andemployers to minimize their anxiety about the patientand to avoid any consequent rejection. Where labeling is aconcomitant of pathological family processes that requireone "sick" member, it may be possible either to modifythese processes, or to help the patient to separate fromhis prior role in the family system.

Avoiding the "Asylum"Pattern

The patterns of institutional care that have beenthe subject of reform ever since moral treatment devel-oped in the late 18th century are no accidental aberrance.


They are, if anything, to be expected in a society that isboth anonymous and individualistic. Bizarre, unpredicta-ble deviants are a threat to society, not so much becausethey are likely to be dangerous as because they arouseinner anxieties and set a dangerous example. Suchindividuals are best "put away" in institutions capable ofprisonlike controls. Therefore the task of staff in thera-peutic settings still includes a constant resistance to theencroachment of pressures toward control rather thantreatment.

Because of its attention to detail, the managementapproach can be a good vehicle for monitoring andlimiting the drift toward control-oriented custodialism. Byfocusing on specific decisions and issues, the question"Are we doing this to control the patient for society, orfor therapeutic benefit?" can be answered day-to-day.Broad rationalizations based on generalities will be lesssuccessful when the staff are all involved with everydayissues concerning their individual patients. Of course, it isalso necessary to maintain a strong overall valuation ofhumane and therapeutic care to uphold a managementemphasis on protecting the patient from society's fears.The surest way to do this is to include the patient as anactive participant in management's decisionmakingprocesses (a point that will be illustrated when I discuss"Therapeutic Community").

Medication and Milieu

The availability of psychotropic drugs has had awidespread impact on all psychiatric care, especiallywithin institutions. The major tranquilizers, the antide-pressants, and drugs such as lithium offer means of alteringthe symptoms of the major disorders associated withadmission. From the point of view of milieu treatment,drugs are enabling. A great deal more can be done with apatient who is not so withdrawn or excited as to beinaccessible to social interaction, and who can communi-cate meaningfully with staff.

One aspect of drug treatment can be a pitfall for milieutreatment. Drugs offer a relatively easy way for staff toachieve control of deviant behavior. But a quiet ward isnot a therapeutic ward. The dosage and effects ofphenothiazines must be carefully monitored so thatnighttime sedation and antipsychotic effects are notgained at the cost of the patient's being sedated, semi-sedated, or parkinsonian during the day. This requires skill,attention, and experience on the part of the psychiatric

staff. For the unit as a whole, it means maintaining anexpectation of alert patient involvement in ward life. Ifpatients are exposed to a hospital culture that expectsdrugs to make people dysfunctional, then drugs will dothis. If the staff, instead, conveys an expectation thatdrugs are not an excuse for passivity, withdrawal, or day-time sleeping, these are unlikely to occur, except wheregenuine drug effects are operant. Put another way, thestaff can make the placebo effect work for the patientand the milieu.

A second aspect of drug therapy that interacts with themilieu is the pattern of medical roles enacted around thegiving of medications. Standard hospital practice makesthe drug sequence part of the medical model of care: M.D.prescribing, nurse administering, aide checking and report-ing behavioral effects, and patient passively receiving. Thismodel and these roles are not necessary and should bemodified or altered to f it the milieu program. In mostcases there will be some requirement for medical or staffsupervision of drug treatment. But usually it is possible toshare the responsibilities revolving around drugs to aconsiderable extent; all staff members, and patients aswell, can be educated about dosages, side effects, andtarget symptoms. With experience, nonmedical staff, andeven the patient, can recommend the choice of drug andthe dose and can monitor effects as well as, or even betterthan, the psychiatrist. The educational process leading tothis can become part of the milieu treatment program as apatient learns to monitor his own drug reactions, orparticipates in doing so for other patients.

Phases of the "Patient's Career"

The critical issues in milieu treatment will be largelydetermined by two aspects of what has been referred to asthe "patient career": the personal aspect and the institu-tional aspect (Goffman 1961 and Levinson and Gallagher1964).

There is a highly individual history of problems andtreatment for each person, differing with each institutionalinvolvement he experiences. Is this an acute break in apreviously well-functioning individual? A recurrence of anacute, intermittent problem? A deterioration of a margi-nal adaptation? Hospitalization with a diagnosis ofschizophrenia can imply a great variety of life-patterns,even when the term is used conservatively. The goals oftreatment—and the role of the milieu—must be adjustedaccordingly.


In the case of an acute break with a previous history ofgood function (i.e., "reactive" schizophrenia), the goalswill include attention to the developmental and environ-mental stresses that precipitated illness. The treatmentsetting may provide opportunity for corrective experi-ences with a surrogate milieu "family" and an intermedia-ate-length treatment (1 to 6 months) may be valuable,avoided by offering positive reinforcements, primarily forserious therapy work, and by mildly discouraging sympto-matic behavior, especially through peer norms and pres-sures.

Patients with recurring hospitalizations usually needencouragement to avoid deepening their institutionaldependency and help in dealing with environmentalstresses that may have precipitated the recurrence. Thusthe focus of the milieu here would be only briefly on thepatient within the milieu, and would rapidly shift to thehome (family, living unit, job setting). This focus mayreveal some change, usually in the person's emotionalsupport network, that explains the recurrence. Thehospital staff's active involvement with the outpatienttherapist will be valuable. With such hospital izations, staffmay need assurance that their efforts are not Sisypheanlabors but are meaningful and effective. It may be helpfulfor them to realize that expectations for a recurrentpatient are limited and must be reevaluated from year toyear or over several admissions. In cooperation withoutside therapists, goals can be set that involve verygradual shifts toward long-term change, with readmissionfrequently serving as an opportunity to effect steps in thisdirection.

For the chronic patient, institutional care can be madetherapeutic even when discharge is impossible. In this casestaff members need to identify clearly the limited range ofchanges possible and to adjust their sights accordingly.Behavior modification approaches and token economyprograms can bring about impressive increments of newbehavior (Lindsley 1960). Discharge should be carefullyevaluated to assure that it will actually be an improvementfor the patient. If it is not a goal, then patient and staffshould adopt an attitude of trying to maximize theopportunities for making life as rich and varied as possiblewithin the institution.

Each institution has a place in a wider network oftreatment agencies. Patients usually come to the institu-tion from some other agency and leave for further care byanother agency (residential or outpatient). We have

learned that much behavior is situationally determined,i.e., it is a result of the impact of the setting on theindividual, or of an interaction between the two. Thus inevaluating any individual, it. is important to know hisparticular route to the present milieu and his behavior inprior settings. Much can be learned from this to thebenefit of all who are presently concerned. The tempta-tion in therapeutically oriented settings is to assume thattreatment elsewhere has been a failure and to "start fromscratch." But interactions from previous settings are oftenrepeated, so close examination of what went well andwhat did not in prior treatment will be helpful.

Similarly, outcome of a particular treatment experi-ence is highly dependent upon the setting and the type oftreatment to which a patient is discharged, and upon theeffectiveness of the transition. A poor transition periodcan sabotage the best aftercare program. If a patient hasbecome involved in the treatment, he will experience anatural loss at discharge and a stress with the change to anew environment. It is, therefore, especially importantthat the termination of involvement in itself be a phase ofmilieu treatment, with time and attention given to it informal and informal aspects of therapy. "Acting-up" canbe anticipated in the form of avoiding medication,premature departure, or reemergence of symptoms. Theschizophrenic may find it difficult to express sadness overthe loss and to handle the anxiety of change. Farewellrituals such as goodbye parties may be useful in helpinghim cope with grief, since these provide a readymadeformat for the expression of feelings and for clearly andpublicly saying goodbye. In therapeutic meetings the lastdays or weeks can be a time of review, especially if thepatient's progress is slipping backward. Staff can alsoassist the transition by encouraging or even requiring theinitiation of aftercare considerably before the departureitself, and by encouraging or requiring a return to thetreatment setting for a few days or weeks after leaving.

The "Milieu of the Milieu"

In the design, evolution, and operation of a milieutreatment program, careful attention must be paid to thewider framework within which it is operating. Thisframework almost inevitably imposes constraints upon theinternal program in terms of anticipated length of stay,staffing patterns, and referral procedures. Both a brief-stay, acute unit that treats first-break and recurring


schizophrenic episodes and a State hospital unit withchronic schizophrenics can have effective milieu programs.Implementation of these programs will vary considerably.It is most important to observe the limits and strengths ofa given milieu; often limits can be converted intostrengths. For example, a poorly staffed ward for chronicschizophrenics can utilize the skills and experience ofnursing aides and patients themselves in ways that wouldnot be considered in well-staffed settings.

An examination of the framework of the milieu mayreveal that some assumed limitations do not exist. Forexample, a brief treatment program may find it possibleto develop its own aftercare services to avert readmissions.Liaison with other agencies may provide access to newresources and alternatives, unburdening the treatmentstaff. Some milieus build a wall around themselves,priding themselves on their programs. This may be auseful contribution to internal cohesion, but it does notnecessitate poor relations with the larger milieu. Certainpersonnel may specialize in bridging the gap to otheragencies.

Therapeutic Community

The Therapeutic Process

Therapeutic community is not created by groupmeetings, patient-staff meetings or even by patient govern-ment. These may be structural aspects of a therapeuticcommunity program, but by themselves they do notassure that therapeutic community will function effective-ly. Effective functioning requires that certain processesoccur that are critical to the therapeutic experience. Isuggest that these processes be classified in three cate-gories, roughly sequential (Almond 1974b). These are:attention saturation, behavior modification, and roleparalleling.

A ttention Saturation

This involves the use of one or more of a variety ofpowerful techniques to direct a significant proportion ofthe sufferer's attention away from his inner preoccupa-tions in order to make social influence possible. In thecase of the schizophrenic individual there is usually apreoccupation with some form of autistic experience:

hallucinations, paranoid ideation, delusional thoughts,diffuse anxiety, thought disorganization, empty depres-sion. While we know that many schizophrenics areexquisitely aware of their environments, the power oftheir psychotic experience (along with its frequentsecondary-defensive function) prevents engagement withthe environment. Therapeutic communities seek to engageattention by active, often-intrusive social contact. Thismay take the form of one-to-one contacts between thepatients or staff (including individual psychotherapy);group meetings, small or large; and charismatic contactwith a leadership figure. In these various contacts,interpersonal social pressure is used to convey to the newpatient the importance of involvement in the community.In non-Western healing communities and American en-counter groups, the variety of techniques for attentionsaturation is wider, including intoxicants, emetics, andcathartics; movement, dancing, and ritualized chanting;complex religious ritual activities; and verbal attack oncharacter patterns and symptoms (Almond 1974b). Inconventional psychiatric settings, antipsychotic drugtherapy is perhaps the most powerful technique forgetting the schizophrenic patient's attention. In additionto drugs, therapeutic communities use certain socialpressures to engage the patient and token economies userewards. Whatever the technique, it is important torecognize that a milieu can have little influence before ithas gained the patient's attention.

Behavior Modification

In general terms, this is a process of engaging thepatient in a give-and-take situation in which he isrewarded for behaviors desired by the milieu and is helpedtoward goals of value to himself. As the newcomerincreasingly attends to his environment, the staff canbegin to selectively reinforce desirable behaviors. Thesewill include behaviors that make for an effective com-munity, such as taking responsibility for other patientsand community needs. Also important to reinforce arebehaviors valuable to the individual, such as the achieve-ment of changes in symptomatic behavior, in recurrentself-defeating patterns, and in relationships. As timeprogresses, the goals will move from diminution ofsymptoms to interpersonal changes and then to prepara-tion for discharge. A sequence of behavior levels, ward


Figure 1. Movement of an acute schizophrenic patient through a therapeutic community ward-Sequence of upward progress.

PRIVILEGE STATUS

DISCHARGE

Dischargedate set

8UJ

8tra.UJ

Q

IO

Job-huntingapproved;outsidetherapyinitiated

tLonger

a

Passes tovisit athome

PatientAdvisoryBoard

Monitorpool

Buddysystem

Unobservedstatus

5-minutechecks

BEHAVIOR LEVEL

THINGS GOINGSMOOTHLY WITHLENGTHY DAY PASSES?

SUCCESSFUL IN JOBPLANS, PASSES,OUTPATIENT THERAPYARRANGEMENTS?

v«tPERFORMING WELLIN RESPONSIBLEWARD ROLE?

No

No

a Accompanied[Jj by patient

i t« Accompanied2 by staff£ member

ADMISSION

ACTING RESPONSIBLYTOWARD OTHERS?

ACTING RESPONSIBLYTOWARD SELF?

Yes

DISCUSSINGPROBLEMS?

Yes

TALKING SENSE?

JTALKING?SOCIALIZING?

Yes

PHYSICALLYMOBILE?

No

No

No

WARD RESPONSE

Social support; delay ofdischarge; explorationof problems in leaving ward

Assistance for off-wardproblems (advice on job,household, school);group support

Social pressure; delayof passes and dischargepreparations

Loss of monitor status;privilege freeze; shaming;responsible behaviorexpectations discussed

Privilege freeze; socialpressure; responsiblebehavior expectationsdiscussed

Pressure to discussproblems openly; argument,shaming; social supportfor self-scrutiny

Irrationality ignoredand/or discouraged;patient treated as thoughhe were rational.

Treated as though heunderstands; socialpressure to communicate;silence ignored

Group pressure, encour-agement; guided throughward routines

\


responses, and reinforcing privilege statuses for onetherapeutic community ward dealing with a hypotheticalacute schizophrenic patient is diagrammed here (figure 1).

Role Paralleling

The third aspect of therapeutic community processrevolves around the tasks of delabeling (relabeling), andthe new social role and self-concept that result. From thefirst moment of entry (or even before, when there is awaiting list for admissions), the patient can be shown arole modeled after healthier, more effective members ofthe treatment community, both staff and other patients.A patient "sponsor" who shows the newcomer around isdemonstrating that patients can assume functions typi-cally carried out by staff. Patients taking blood pressures,monitoring upset patients, making decisions about eachother's privileges, or participating therapeutically (in atherapist role) in group meetings—all exemplify therole-paralleling process in action. The process is two-sided:On the one hand, the patient who plays the stafflike roleis asserting his capacity to be competent, helpful, andresponsible. We have learned from studies of role playingthat enacting and transmitting to others a set of beliefs arethe most powerful ways to incorporate them. Here, thebeliefs or conclusions relate to such questions as, "Am Isick or well? Competent or incompetent? Active orpassive?" Enacting a role closely paralleling staff rolesleads patients to the more positive answers. On the otherhand, each bit of role-paralleling behavior shows the restof the community, both patients and staff, that patientsare not limited to a sick role.

Role paralleling requires sensitivity and careful workby the staff. Staff members must be willing to relinquishsome of the protections and powers of their traditionalroles and to take risks by giving patients more responsibil-ity. But at the same time, they must constantly monitorthis process to be sure that these increments of responsi-bility and power can be handled by the patients. Withschizophrenics, these cautions in relinquishing staff func-tions are especially important. Patterns of dependencyand passivity are often so fixed that compliance can bemistaken for real cooperation. The quality of the roleperformances must be carefully evaluated by the staff. Itis not enough to share power; once it is shared, the staffmust constantly assess how it is being used. Ultimately,responsibility for treatment remains with the staff. When

signs of patients' misuse of power appear, the staff mustmove in and actively insist on change.

Charisma and Communitas

Any Therapy requires the presence of some specialconditions that facilitate the difficult process of personalchange (Frank 19-73). Here these are interpersonal:Either individual-individual or individual-group. I refer tothe special quality of the bonds that develop in thesetwo kinds of interaction as healing charisma and com-munitas; respectively (Almond 1974b).

Charisma refers to the special feelings that developbetween two members of a therapeutic communi-ty, one usually being of higher rank or greater experiencein the community than the other. Communitas refers tospecial relatedness existing within groups or within thecommunity as a whole. The two kinds of relatedness havein common the creating of a sense of elevation, of makingthe participants something more than ordinary, able totranscend ordinary limits. Developing and maintainingcharisma and communitas is the task of the long-termstaff. Freedom must be given for staff members todevelop their charismatic qualities. These qualities varyfrom one person to another—charisma is not a fixed set ofattributes, but a capacity to evoke certain responses inothers. For mental health workers interacting with schizo-phrenics, charismatic behavior may well lie in quiet,empathic listening. Senior staff must ensure that theirown charisma is actually transmitted to subordinates, i.e.,that it enhances the latter's charisma, and that it istransmitted in turn to the patients. This means thatsupervisors must encourage originality, a sense of special-ness, in each staff member. Charisma can be transmittedto staff and patients throughout the community by wayof,role expectations. These define the possibilities fortaking on responsibilities, confronting difficulties, voicingproblems openly, and so on—for tackling things that arechallenging.

Communitas, the general atmosphere of specialness inthe therapeutic community, can be facilitated by main-taining certain values within the total culture. Thisincludes the valuation of interactions such as shaiingproblems, providing mutual support, and having a sense ofcommon cause and of cohesion as a group. Any particularcommunity may (and should) have its own, unique values


Figure 2. Diagram of the mutually supporting interplay between charisma and communitaswithin the therapeutic community. /

COMMUNITAS

Feeling ofcommunitassupportsall norms

Every member and every /subgroup is important /

This is a special place wherepeople transcend ordinary limits

HEALINGCHARISMA

Normsincludevalue ofcommunity

COMMUNITAS NORMS

THERAPEUTIC NORMS

Guidance for behavior

Roles exemplify norms

Effec-tivenessenhancescharisma

Support forextraordinaryrole behaviorfrom higherranks

CHARISMATIC ROLES

THERAPEUTIC ROLES

and styles. The training of incoming staff members andthe reinforcement of positive, patient behavior in theseareas can ensure that the community's values are norms ofdaily life.

The mutually supporting interplay of healing charismaand communitas, and their manifestation in the normsand roles in a therapeutic community, are indicated infigure 2. This network of interactions is crucial tomaintaining effective processes for the milieu treatment ofindividual patients. In fact, the interplay of individualtherapeutic efficacy is circular, as is shown by the diagramin figure 3.

Authority and Nurture

Traditionally, mental hospitals have emphasized au-thority or nurture or both as primary functions. As weevolve toward a more therapeutic attitude, these twoaspects of residential care continue to be importantelements. Certainly these are major themes in anytreatment system dealing with schizophrenic problems.But either extreme of these two functions is incompatible

with therapeutic community-whether permissiveness orauthoritarian control, or indulgence or deprivation. In astudy of one particularly effective therapeutic communi-ty, as measured both by immediate results and followupstudies, Almond, Keniston, and Boltax (1968) found thatthe culture emphatically did not value either authoritariancontrols or indulgence by staff. Instead, emphasis was onself-control of impulses bolstered by charismatic author-ity, medication, and social pressure. Similarly, on thisparticular unit the patients' need for nurture was fulfilledthrough the general feeling of communitas, which pro-vided social support for positive self- or community-en-hancing behaviors rather than unconditional support.

While these observations on authority and nurture holdtrue for any therapeutic community, they are particularlyimportant in dealing with schizophrenic individuals,whose previous experiences with authority and love haveso often been aberrant, or even blatantly destructive. Toomuch love can be overwhelming to those with uncertainego boundaries, paranoid ideation, and low self-esteem.Too much freedom can be frightening where there is apoor sense of self-control, a struggle with aggressive


Figure 3. Interplay of the therapeutic processes of a therapeutic community in terms of patient'sprogress.

Efficacy of the communityis renewed; charismaticroles of staff and com-munitas norms are validated

Patient espouses the normsof communitas, and a charismaticallyenhanced patient-as-therapist role

(G)

Patient returns home;outpatient therapy;patient views self asable to live and workoutside hospital

(D)

Patient learns todeal with own lifeand problems

(H)

Interactions withexperienced patients

Dealing with

privilege sequence

Interactions

with staff(A)

Medications

Specific individual,

family therapies

Patient at admission:viewed by others and/orself as "sick," i.e.,disabled, dependent,irresponsible (A)

Events leading to patient's admission


impulses, and a weak sense of differentiation betweenfantasy and reality. These reactions are corroborated notonly by behavioral observations, but by schizophrenicindividuals' describing their subjective experience withtreatment.

Milieu Treatment of Specific Problemsin Schizophrenic Disorders

No simple one-to-one prescription of milieu responsesfor particular behaviors in the schizophrenic repertoire isappropriate. In fact, with much symptomatic behavior,milieu treatment should be continued without regard tothe symptoms. Here I am speaking of hallucinations,delusions, and other "bizarre" behaviors. When these areoccurring, staff can clarify reality- and try to avoiddistortions of ordinary behavior patterns and socialexpectations in their own actions. In other words, I amsuggesting that except where specific responses tosymptomatic behavior are part of the treatment valuesystem it is best to ignore or neutralize their impact. Thiswill avoid needless reinforcement and secondary gain. Ifthese symptomatic manifestations are accompanied byanxiety, this can be identified and appropriate reassurancegiven through such measures as special ing, extra medica-tion, or physical contact. Specialingcan be done by otherpatients, in fact often more effectively than by staff, sincethe benign meaning of the contact is more likely to beclear to the patient being treated. It is often helpful toalert the entire treatment community to one individual'scrisis and to present it as a community problem. Lockingdoors or other forms of protective reaction may be usefulin enlisting community aid, and such measures can oftenbe taken in consultation with the patient group. Iwould encourage the use of additional contact with thepatient first, to avoid what might become a regressiveinvitation to the community as a whole.

Much the same can be said about the treatment ofself-destructive, suicidal, and assaultive behaviors. Herestaff may have to participate more directly. For example,the black depression accompanying many acute schizo-phrenic episodes is often not characterized by thepsychomotor retardation occurring in other depressions.Suicidal behavior in such instances may be more unpre-dictable, sudden, and earnest than in other kinds ofdepressions. Assaultive behavior requires staff assistance,because it can evoke fears of loss of control in otherpatients, as well as constituting a danger to staff and the

patient community. Emphasis should be on reassuring theassaultive patient about his own self-control and theavailability of supplemental human, chemical, or physicalcontrols if necessary. A firm, unpanicked attitude willoften obviate the need for other controls. If they are used,clear explanations should be given to the patient involvedand to others as well, emphasizing the expectation thatthis will be a temporary situation.

Manic behavior in schizo-affective disorders (or inmisdiagnosed cases of mania or hypomania) is handled asan exception to many precepts of milieu and therapeuticcommunity treatment. Manic patients do better with lessstimulation and thus should not participate in large groupmeetings, especially those with an unstructured format.Nevertheless, the patient community can be enlisted inhelping patients through such periods, setting neededlimits to their self-stimulating (and often entertaining)cycles of activity. When such behavior is under control oris waning, manic patients can be valuable communitymembers and need to be encouraged to put their energyto appropriate use.

It is best to ignore paranoid thinking. A differentiationshould be made, however, between chronic paranoidschizophrenia, a psychotic decompensation in a paranoidpersonality, and paranoia as a primitive organizing at-tempt in an acute, undifferentiated schizophrenic episode.In the last situation, some reality clarification andinterpretation may be helpful; in other manifestations, theparanoid process is invariably more powerful than anyrational argument that can be offered. It will be moreconstructive to emphasize the expectations and limits ofthe milieu and to disregard paranoid delusions than toargue. The patient can usually modify the paranoiddelusions to comply with these limits once his anxiety andhostility begin to diminish.

Frequently, severe problems of dependency and passiv-ity characterize schizophrenics, either acute or chronic. AsI have already indicated, treatment of these problemsrequires careful evaluation and planning. The amount ofchange possible and the factors underlying the patterns(such as a person's role in his family) should be evaluated.Then graded steps toward change can be outlined, withrealistic provision of positive reinforcement of progress.

Perhaps the most challenging problem in milieu treat-ment is that described by T.F. Main (1957) as "theailment": the patient whose pathology seems to feed onthe help he receives. Such patients, who tend more oftento be borderline personalities than schizophrenics, require


a united front from the milieu to avert their magnificentcapacity to recreate their inner good/bad splits in theworld around them. Discharge may be necessary, andsurprisingly, often short-circuits the pattern of self de-struction. It is important to recognize that for suchindividuals the warmth and acceptance of the milieu, withits possibilities for love and intimacy, evoke paradoxicalattitudes of self-hatred. Outpatient treatment over a longperiod and/or intermittent, brief hospitalizations maybecome more effective as trust slowly emerges.

Specific Formats and Activities

I have obviously included little of the "how to" varietyof prescription for milieu treatment. This has beendeliberate. I am firmly convinced that the best programdesign evolves from the staff directly responsible fordeveloping and maintaining the program; only in this waycan the particular local factors—the variety of patientsencountered, their length of stay, the staff skills andinterests—be responded to most effectively. Yet it is alsotrue that milieu programs often apply a rather routine setof activities without much consideration of their implica-tions and interactions. The "standard" milieu program, asI have observed it, usually includes one or more communi-ty meetings weekly; two to five small group meetingsweekly; one or more family group meetings; some form ofpatient government; and such usual activities as special-ized therapies, exercise, arts and crafts, and outings. Theseare all too often uncoordinated, each having its own staffleadership and little continuity other than the patienthimself. What does each of these therapy activities do?How can they contribute to an overall milieu program forschizophrenic patients? What other therapies and activitieswould be useful additions, and in what way?

Large, community group meetings (sometimes calledpatient-staff groups) are best understood as ritual situa-tions. Arrivals and departures of patients and staff areannounced; ward issues and crises are discussed. Wherepatients participate in decisionmaking the communitymeeting can be a time of review, with agreement orchallenges by the staff reinforcing or correcting patients'handling of responsibility. I personally do not favor anunstructured, open format for large meetings. Suchsituations have been shown to be ineffective as a means ofincreasing patient participation and sharing power withthem (Rubenstein and Lasswell 1967). In fact Rice (1971)

discovered that such settings frequently induced regressedbehavior in normal groups. Structuring large meetingsdoes not mean dictating to patients, but simply that thestaff must create or insist on structure. Often the formatcan emphasize patient leadership. One individualizedversion of the large group meeting, held in a setting wherepatients and staff were divided into three semi-autono-mous small groups, had patients giving weekly informa-tional reports on the progress and problems of groupmembers to the other two groups.

Small groups are often the heart of a milieu program.In dealing with 5 to 10 patients it is possible to attend toeach member, especially if the group meets daily or atleast several times weekly. The staff may prefer to have anunstructured format, or to use techniques such as roleplaying. It is best for some, if not all, group therapists tobe part of the regular ward staff, so that active issues frompatients' daily lives can be attended to. Unlike outpatientgroups, staff should bring up such issues and activelyfacilitate patient participation. Interpretations should belimited to the here-and-now, rather than including psycho-genetic and dynamic factors. The role of the leadersshould also emphasize their function as "social engineers"monitoring the norms, cohesion, and effectiveness of thegroup. Leaders may prefer to work one-to-one withpatients while the rest of the group listens. In this case,the leader must ensure that the impact of one patient'sexperience on the others is explored. It also requiressensitive collaboration to avoid making other staff mem-bers into spectators. Regardless of therapeutic technique,the small group meeting offers the staff opportunities fordeveloping individual leadership styles and personal charis-ma.

The small group can be powerful therapeuticallybecause it evokes a "family transference" and can thus bean effective corrective experience. In some cases the smallgroup can be the administrative unit as well, thuscombining therapeutic community processes with theseprimary group forces. This system may work best inintermediate-stay programs, where admissions and dis-charges are gradual enough so that there is moderatestability of membership. When the staff team itselfremains constant, opportunities for staff development,training, and leadership increase.

Patient government will depend to a large degree onaverage length of stay. In acute units (average stay 1 to 3weeks), patient government may not be possible. If there


are enough responsible patients to make it work it can beuseful, but it needs active collaboration and supplementa-tion by staff, with patients' roles and responsibilitiesclearly defined. In intermediate-stay units, patients maybe able to run at least their own part of the program, withone or more staff as advisors. In long-stay units patientsmay be given a flexible amount of staff help, dependingon their level of competence. The value of patientgovernment for schizophrenic patients lies in its opportu-nities for enacting roles of real, yet supervised, responsi-bility. Such experiences open up a variety of possibletherapeutic events, both on the level of ego functioningand, less obviously, in the interpersonal transactionsinvolved in the assumption of responsibility.

Specific therapeutic techniques such as psychodrama,art therapy, gestalt therapy, assertiveness training, danceand movement therapy, and other techniques can beuseful within a milieu program. The choice of theseshould be determined by staff interests and the needs ofthe patient population.

Behavior modification is, in my view, not a specifictechnique, but a way to conceptualize and implement anytherapeutic activity. The concepts may be applied tomoment-to-moment interactions or to entire therapeuticprograms.

Individual therapy within a milieu program can have awidely varying role. From the milieu point of view, it isimportant that individual therapy and milieu treatmentcomplement and support one another. The individualtherapist can use the events of the patients' dailyexperience in the milieu to focus more accurately on theintrapsychic issues aroused by the milieu. It is unrealisticto try to recreate the conditions of outpatient therapy byconsidering the milieu a separate world "outside" therapy.Thus confidentiality should generally be conditional, inrecognition of the reality that both therapist and patientare members of a larger community. In fact, sharing ofsensitive material in individual sessions is frequently a firststep toward sharing it more widely. The therapist canoften successfully encourage the patient to take up issuesthat are important to him with the community. If thesecrets shared involve dangerous or self-destructive behav-iors, the therapist, I feel, can be more constructive inpointing out why he must share this concern with othersin the milieu than he can in preserving confidentiality.With regard to any one patient, these issues may requireindividualized, sensitive consideration. The point is thattoo often individual therapy is seen as separate from

milieu treatment, whereas it is, infact,merely a formalizedversion of the many one-to-one contacts that occur in aresidential setting.

Application of Milieu Treatment

The settings in which milieu treatment is used varygreatly, and such variations are necessarily accompaniedby modifications in the technique. If we consider thetreatment of an acute schizophrenic episode, for example,the application of milieu techniques would be different inan acute-treatment general hospital ward, an inter-mediate-stay setting, and a long-term psychotherapeuticcenter. The goals and styles of these milieus are verydistinct, and milieu techniques must be appropriatelyadopted in each case.

In an acute-treatment setting, the goals for treatmentof a schizophrenic episode include symptom reduction,some degree of restoration of social contact, and prepara-tion for aftercare. Staff roles will be active with the staffmembers coming to the patient. Antipsychotic medicationwill, in most cases, reduce autistic preoccupation within afew hours or days and will enable social contact. Even in abrief-stay unit some degree of support and involvement byother patients can be expected, but staff must take thelead. Evaluation, as an important part of aftercare referraldecisions, is also a staff function. A major milieu issue insuch a unit is the maintenance of behavior consistent withthe expectations of both patients and staff that recoverieswill be rapid. Senior staff thus must retain sufficientauthority to support the unit culture. In terms ofstructure, such units function best when small, or whensubdivided into small staff teams caring for 5 to 10patients. This enables a more direct focus on theindividual and provides a smaller, familylike social unit forthe patient to relate to instead of an overwhelmingnumber of new faces. Small-group therapy techniques canthen be employed as a primary modality, with little or notime spent on large community meetings. Within the smallgroup, patients may be able to go through at least a partof the role-paralleling process.

In an intermediate-stay setting (1 to 6 months' stay),important therapeutic work can be done beyond symp-tom control and disposition-exploration of such precipi-tating factors as family dynamics, social limitations, workor school problems, recent personal loss, stress, or failure.In addition to identifying such causes, and independent of

ISSUE NO. 13.SUMMER 1975 25

whether they may be seen as contributory or secondary tothe schizophrenic process, intermediate-stay treatmentmakes possible some reworking in these areas. This canoccur on two levels: 1) on an "as i f" level, withtransferencelike reenactments of, for example, familypatterns within the milieu; 2) in real-world changes, suchas a return to school or work, with the support andscrutiny of the milieu.

These reworking experiences require a dynamic, flexi-ble milieu. Even when patients enter as acutely disturbed,it is vital that there be strong expectations for a quickreturn to active, competent behavior. Thus, therapeuticcommunity techniques can be more fully employed.Senior staff must model the sharing of power andresponsibility by doing so with line staff, and must guidethe line staff in doing so with patients. Structure of thetreatment setting may be more complex than is usual,with patients involved in a variety of different groups,meetings, and activities. This provides a better simulationof the challenges of life in the outside community andprovides more varied situations for improving deficientego skills. Family therapy can be particularly useful, withmultifamily as well as single-family meetings offeringdiffering opportunities and supports.

In a long-term residential treatment setting (6 monthsto several years) aimed at major changes in personalityand the repair of early developmental deficits, the milieuplays an important collaborative role with individualpsychotherapy. Unlike psychoanalytic psychotherapywith outpatients, where the patient takes responsibilityfor acting-out behavior, the patient, the therapist, and thetherapy are all part of the milieu. While a degree ofprivacy may be necessary for the psychotherapy relation-ship, major developments should be shared with themilieu staff and vice versa. In fact, recent examples of thedyadic model do not make such a clear division betweenpsychotherapy and milieu staffs.

In long-term milieus, it is possible and desirable toestablish a full program of activity appropriate to the ageand needs of the patients. Thus, school programs, jobs,recreation, and social relations—both intramural andextramural—should be provided for. Emphasis should beplaced on group and community meetings that arerelatively structured and that relate to the real roles andresponsibilities of the patients in the setting. Whilelatitude must be allowed for individual creativity and forperiods of regression related to the psychotherapy proc-

ess, this must be carefully distinguished from patients' useof the milieu for resistance. This is especially true whenthe pathology of several patients combines in an antithera-peutic culture. Limit setting, and guidance toward moreappropriate handling of affect is as important here as it isin brief-stay settings.

Whatever the setting, clinicians can take advantage ofthe standardized measurement instruments now availablefor assessing the qualities of milieus (for example, seeMoos 1974). Using such tools it is possible to monitor,compare, and develop aspects of treatment environmentswith greater certainty. Outcome research is now beginningto relate milieu features to posttreatment status (RobertEllsworth, personal communication).

Summary

Milieu treatment has been discussed here as a set ofconsiderations in the creation and operation of mentalhealth settings that care for patients on a more-than-out-patient basis. Considerable experience has been gained inthe application of milieu techniques in the past 25 years.At the same time, the variety and tasks of milieus haveincreased and become more complex. This is particularlytrue for the schizophrenic range of disorders, where theproblems encountered may range from management ofacute symptomatology to rehabilitation of the chronicallyinstitutionalized. The practitioner of milieu treatmentmust 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 suchunits must be sensitive to phenomena of the institution'ssocial system as much as to individual pathology anddynamics. The resources and limitations of the program'smandate, the strengths and weaknesses of staff, the ebband flow of social dynamics in complex organizations, thequalities and needs of the patient population-all requirecareful attention for an effective milieu. I have reviewedspecific aspects of milieu programs—group therapy, com-munity meetings, patient government, team treatment-toconsider their place in a wider program. The milieumanagement of problems frequently encountered inschizophrenia has also been considered briefly.

I have argued here that the best specific program for agiven milieu is usually devised by the staff who willimplement it. Attention to daily events and planning,which I have referred to generally as "management," is


more critical than the arbitrary use of particular tech-niques of therapy. This emphasis corresponds with theimportance of developing ego skills and enhancing adap-tive qualities in schizophrenic individuals. Similarly, inimplementing therapeutic community I have listed a set ofgeneral therapeutic processes that facilitate the engage-ment and change of the individual patient, as well asprocesses important in maintaining the community as awhole.

References

Almond, R. "Concepts and New Developments inMilieu Treatment." Presented at the International Confer-ence on the Psychiatric Residential Milieu, Stockbridge,Massachusetts, October 9-12, 1974a.

Almond, R. The Healing Community: Dynamics of theTherapeutic Milieu. New York: Jason Aronson, 1974b.

Almond, R.; Keniston, K.; and Boltax, S. The valuesystem of a milieu therapy unit. Archives of GeneralPsychiatry, 19:545-561, 1968.

Braginsky, B; Braginsky, D.; and Ring, K. Methods ofMadness. New York: Holt, Rinehart and Winston, Inc.,1969.

Dunham, H., and Weinberg, S. The Culture of theState Mental Hospital. Detroit: Wayne State UniversityPress, 1960.

Frank, J. Persuasion and Healing: A ComparativeStudy of Psychotherapy. 2d ed. Baltimore, Md.: TheJohns Hopkins Press, 1973.

Goffman, E. Asylums. Garden City, New York: Dou-bleday & Co., Inc., 1961.

Levinson, D., and Gallagher, E. Patienthood in theMental Hospital. Boston: Houghton Mifflin Co., 1964.

Lindsley, O. Changing the behavior of chronic psy-chotics by free-operant methods. Diseases of the NervousSystem, 21 (Monograph supplement): 66-78,1960.

Main, T.F. The ailment. British Journal of Psychology,30:129-145,1957.

May, P. Treatment of Schizophrenia. New York:Science House, Inc., 1968.

Moos, R. Evaluating Treatment Environments. NewYork: Wiley Interscience Publication, 1974.

Rice, A. Learning for Leadership: Interpersonal andIntergroup Relations. New York: Barnes and Noble, Inc.,1971.

Rubenstein, R., and Lasswell, H. The Sharing of Powerin the Psychiatric Hospital. New Haven, Conn.: YaleUniversity Press, 1967.

The Author

Richard Almond, M.D., is the author of The HealingCommunity: Dynamics of the Therapeutic Milieu. He is inpractice with the Collective Psychotherapy Center, PaloAlto, Calif., and on the Clinical Faculty of StanfordUniversity Medical School.

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