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A therapeutic environment does not just happen. It must be built systematically and rebuilt daily, the effort itself creating an atmosphere alive with growth in staff as well as patients. This paper will define milieu therapy, identify the underlying principles upon which such a program is based, describe some of the difficulties encountered in maintaining a therapeutic environment and suggest some ways of dealing with them.
Milieu therapy is an idea "whose time has come." Since Maxwell Jones first described the "therapeutic community" in 1953,' the hospital environment has been recognized as a variable in the psychiatric patient's treatment plan, and it is now widely accepted as a valuable tool in altering behavior. In spite of the fact that the past ten to twenty years have seen the development of a large body of journal literature on the subject of the therapeutic milieu, psychiatric textbooks in general, both medical and nursing, devote but a scant paragraph or two to the subject. I can only guess the reason for this paucity of attention is that professional schools focus their teaching efforts on the treatment of individuals. Management of group treatment programs is a self-taught skill for physicians and nurses. Yet the creation and management of a therapeutic milieu will be the task of the head nurse and her charge nurses in any psychiatric inpatient setting. The Standards of Psychiatric-Mental Health Nursing dictate it.2 The patient deserves it. Our judicial system, in defending every patient's right to the least restrictive environment, demands it. The community mental health movement to establish care for the mentally ill on an outpatient basis has accelerated the need for preparing the patient for self-directed care in a short period of time at the inpatient, residential level. And the President's Commission on Mental Health spells it out succinctly: "Whenever possible, people should live at home and receive outpatient treatment in the community. When they cannot, the facility in which they are treated should offer the maximum possible independence. "3 Providers of inpatient mental health care must respond to these demands, and the use of therapeutic milieu methods would seem to be the modality of choice from which to begin.
The concept of milieu therapy as it is used in this article is both...