Haven and Hope

Modern milieu therapy is a well-known approach in psychotherapy circles that can invoke a broad range of viewpoints due to its long history. For parents whose children have mental health or socio-emotional challenges, it can be helpful to understand this form of therapy as a treatment option in its modern form. The milieu therapy concept took shape in the late 19th century, with roots that go back to the 18th, when French physician Philippe Pinel reframed psychiatric treatment from how it was traditionally provided at asylums, toward a form of care that emphasized compassion and empathy. Other everyday names, like Freud and Bettelheim, are synonymous with its application. When milieu therapy took root in a range of residential and in-patient settings in the 20th century, several treatment centers used the term to describe the care of emotionally troubled patients, particularly children. Today in the 21st century, full-time treatment programs, such as those offered by the O-School, continue to offer milieu therapy as one of the most effective modalities for treating students with severe emotional and mental health issues.

What is Milieu Therapy?

At its most basic level, milieu therapy considers all aspects of a child’s experience to be therapeutic, allowing them to continually learn and practice skills that will serve them for the rest of their lives: everything from caring for themselves and maintaining a regular schedule, to learning how to set and work toward goals, to interacting with others and forming healthy relationships. At the O-School, for example, this is achieved by working with both peers and staff in a 24/7, working therapeutic community based on the following six components:

1. Supportive and therapeutic relationships

Our belief is that change and growth of the individual cannot be forced. Instead, we apply a normative hand through skilled, caring clinicians who first seek to understand the child, then determine the best path to help them work through their various thoughts and emotional states based on that understanding. This wholly individualized approach has been proven to provide an effective path to real progress and sustained growth. Milieu therapy is all encompassing, across all of the child’s interactions. At the O-School, this is not accomplished through a pre-determined program or strict behavior modification approach. Rather, it is accomplished over time, allowing these interactions to grow into close relationships with both peers and clinicians. Formal, scheduled therapy sessions are still held even though therapy is essentially provided throughout the entire day. Every interaction between staff and peers is an opportunity to grow and learn. The ultimate goal is to build strong internal capacities within each child, rather than fostering change that is merely superficial.

2. Daily routine and structure

Milieu therapy combines school with typical classroom education during the day, along with a structured home-like environment (homework times, mealtimes, social and free times, etc.). This daily structure allows students to feel safe while also providing them with numerous opportunities to explore, learn and grow through an experience that is consistent and meaningful.

3. Continuous exploration of life events

The experiences of daily life, whether positive or negative -- and the chance to examine them fully -- are at the heart of milieu therapy. With the help of skilled guides, students use their own experiences to understand how they perceive and respond to life’s many events. Through this process, they can learn something about themselves and the world. Exploration helps the child gain personal insight, identify strengths, accept challenges and feel capable of facing life.

4. Socialization

Within modern milieu therapy, creating a treatment environment that is safe, predictable and empathetic helps children develop strong friendships within their peer groups. New friendships nurture a new sense of competence and success. Regular extracurricular and social activities inside and outside of the classroom are designed to foster these relationships. They help children discover and build on current interests and passions. During these activities, clinicians and educators engage with the children to ensure all interactions are positive and supportive. When needed, children may also receive coaching on how to initiate, reciprocate and sustain friendly exchanges.

5. A focus on self-care

Modern milieu therapy directs hands-on experiences aimed at developing key life skills that will better prepare children for greater responsibility, independence and adulthood, including:

• Personal Hygiene - There is often a connection between mental health challenges and how people care for themselves. The milieu therapy approach integrates hygiene into the students’ daily routines as a basic expectation to help them establish a consistent practice of physical care.
• Organizational Skills - Executive functioning skills, such as planning, organizing and scheduling are essential for living an independent and productive life.
• Personal Schedule – Children work within a daily schedule designed so that there are many opportunities throughout the day to be responsible for being on time and complete tasks or activities. Schedules are consistent and predictable, without being overly regimented or inflexible.
• Healthy Boundaries – Part of getting along well with others, both authority figures and peers, is establishing healthy and adaptive interpersonal boundaries. These boundaries may include personal physical space, how to disclose and share personal information, or what to expect from others.
• Life Skills Development - As mental health challenges diminish, there is a corresponding increase placed upon the child to resume responsibility to learn and practice life skills such as: personal laundry, money management, shopping, electronics use management, sleep hygiene and time management.

6. A supportive physical space

An immersive milieu creates spaces that are warm and welcoming and that support learning and living. To provide a safe haven for vulnerable students while keeping them connected to life outside school, the O-School has created surroundings that include both a rich learning environment and the familiar furnishings, variety and visual interest that make the space feel like a home. Together, these elements form a carefully constructed learning and therapeutic setting that can bring lasting change to the lives of students, regardless of the challenges they face. Without changing who they are as individuals, modern milieu therapy teaches, guides, encourages, and nurtures students to develop new skills that will help them better understand themselves and their relationships as they re-engage with the world at large.

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Diana Kon, Ed.D., is Co-Executive Director of the Sonia Shankman Orthogenic School and the Brooke Whitted Center. She is an active advocate for students and young adults with exceptional needs. Reach Diana at dkon@oschool.org.