Theoretical approaches in residential child care : the milieu as therapy

Date Posted: Sunday, 31 August 2008

These brief notes accompanied the first session of an induction course for residential child care workers in which different therapeutic approaches that have been used in the group living are considered. The others which will be published on the site in the near future include social learning theory and practice, humanist theory and therapy, behaviourist theory and practice as well as cognitive behaviourial therapy. The psychodynamic approach is already well represented on the site. Readers with some experience of each of these approaches will be aware of the introductory nature of these texts but I hope they offer stimulus for further thought, reflection and reading.

Milieu Therapy

Of all the theoretical therapeutic schools milieu therapy is the one which is most directly associated with residential care. Among its best known protagonists have been August Aichorn, Bruno Bettelheim, AS Neill, Melvyn Rose and Fritz Redl. The word therapy has its base in Greek and means to make well or to make well again. Milieu means environment. In milieu therapy all the attributes of the potential of the environment are brought together to help those who are ‘in therapy’ to feel better about themselves and so to become well again.

Underpinned by psychodynamic principles, the aim of milieu therapy is to provide a ‘total’ social environment in a group living setting (often referred to as a therapeutic community) which meets the physical and emotional needs of those who live there. It is an approach which has been used in mental health settings as well as in the field of residential child care. Those placed in therapeutic communities are generally diagnosed or self-diagnosed as having emotional troubles with concomitant behavioural problems which make them for the time being vulnerable while living in the wider community.

A residential institution providing milieu therapy sets up an environment in which everyday events and interactions are used therapeutically for the purpose of building up the emotional confidence and enhancing the social skills of those who are placed there. In therapeutic communities for young people education is often integrated into the daily routine. This educational intervention (which is in part less conventional than mainstream educational provision) has both educational and social goals and is part of the therapeutic milieu.
The milieu, or “life space,” provides a safe environment that is rich with social opportunities. It is not a static environment but it is flexible and dynamic while remaining focused on the need to provide experiences which will create opportunities for personal development. To do this it uses common structures such as daily routines, consistent rules and activities.

The milieu, or “life space” is set up in such a way that it is constantly supportive. It contains and supports the young person while he or she works through unresolved relationship difficulties, learns to solve problems and develops coping skills. At the same the milieu is a safe place for these developments to be worked through, practiced and integrated into the young person’s growing catalogue of life strategies.

Milieu therapy acknowledges the views of the young person as well as the operational needs of the institution. Examples of these are the young person’s frequent and regular meetings with a keyworker, and, (more significantly in the life of the therapeutic community), the daily community meetings which involve all the young people and all the staff during which the young people can reflect on all the things, between good and bad that have happened to them during that day. From these meetings it is intended that the young people will come to learn about how to accept, and cope with the ups and downs of life. The self evaluation which a young person makes in this meeting tempered as it is by the views of the other young people and staff allows the young person – in a non-threatening setting – the opportunity to see himself as others view him.

In the therapeutic milieu there is a focus on creating a physical environment which echoes the philosophy of care. The decoration of rooms and the fabric and look of the furnishings are warm. Caring for pets and farm animals is often part of the living routine. Food is carefully prepared with wholesome ingredients. It is presented in a way which cherishes the symbolic as well as the real nature of food. Food is eaten communally.

In conclusion the principal goal of the therapeutic milieu is to help the young people feel socially and emotionally integrated in their world without them losing the sense of being their unique selves. The test of the effectiveness of milieu therapy is whether the new stability the young people feel after their stay in a therapeutic community, the new skills they have acquired,and their new found confidence in making relationships can withstand the pressures of the wider community.

Exercises

What are your views on milieu therapy ?
How far do you believe your place of work provides a therapeutic milieu ?
Have you planned the total physical social and emotional environment of where you work ? Do you believe such planning would help the young people ? If you believe it has potential to help young people, do you work to release that potential. What obstacles stand in your way.

Charles Sharpe, November, 2007