Thursday, March 22, 2012

The Milieu

Merriam-Webster defines milieu as "the physical or social setting in which something occurs." Milieu therapy is treatment that intentionally utilizes physical and social context to intervene with multiple clients, typically as part of inpatient, residential, or day treatment. Specifically, it involves proximity within a safe physical space, and group therapy that builds on a sense of community that forms among clients. While a protective physical environment is obviously a primary purpose of inpatient treatment, I think the social environment has greater overall significance for treatment across levels of care.

Of course, while the physical environment is largely under staff control, the social environment is...not. Sure, we influence it - we establish group guidelines, reinforce adaptive/positive/recovery-oriented behavior, and redirect maladaptive/negative/non-recovery-oriented behavior. However, the specific makeup of individuals in the milieu always influences its atmosphere. Anyone who has worked on a milieu knows what I mean. It may be sunny weather...or the atmosphere may be charged with tension, cloudy with depression, slowed like it's under water, or chaotic with manic or anxious energy. Like mood, attitudes also spread easily from person to person so that a stance taken by a subset of the population can spread to the rest of the clients in the milieu. I'm not sure the exact mechanism by which this happens, but I suspect it is some combination of subtle norming, peer pressure and feedback, and modeling.

Since opening at the beginning of February, we have been lucky to have enough positive and motivated clients coming to our partial and IOP programs to bring the whole milieu up to their level. However, as the more motivated and positive people have discharged, the milieu has recently shifted into a more ambivalent or even negative space. I find it more draining to facilitate groups when the milieu takes on this attitude - it takes more out of me to be advocating for change against the current of the population. There is more undertow. And there can also be more momentum in counterproductive directions. As a colleague said yesterday, the group can "get away from you."

However, even - and perhaps especially - with that kind of group, effective redirection can create a course-change that spreads among the population, and ultimately becomes momentum toward change. It's often the case that people become more positive and motivated as they progress in treatment. When they discharge, there can be a less-positive period (like we're having now), but that is (usually, hopefully) just growing pains in the milieu's development, which ultimately lead the group to a higher level of recovery.

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