The Therapeutic Milieu

Some milieux (the plural form of a fancy French word for social settings) are therapeutic, meaning they bring out the best in people; others bring out the worst. If you need an example of those that consistently bring out the worst, think of a maximum-security prison, a busy highway, the cafeteria of a middle school, or the parents’ bleachers at a basketball game. I wish I could give you a list of settings that consistently bring out the best in people, but I can’t. A home, a marriage, a gathering of friends, a workplace, or a church are all places that could be therapeutic, but often aren’t.

If you want to enjoy the therapeutic properties of a well-functioning milieu, you either have to be very lucky to find yourself in one, or you must create it, yourself. Fortunately, I’ve had a hand in creating a therapeutic milieu or two in my day, so I can tell you how it’s done. For many years, I worked in a program where almost two hundred people with serious mental illnesses and intense addictions came to spend the day together, every day. If we could make that kind of gathering therapeutic, then you should have no problem with yours. Pay attention to the following factors.

Safety
Safety is the most important component of a therapeutic milieu. Danger doesn’t bring out the best in people. Despite having almost two hundred potentially psychotic, fearful, depressed, and drug addicted people there all day, we rarely had trouble in our program. Medications helped, but we also kept an ear out. There was always staff around to intervene in a calm manner should tensions arise.

If you’re trying to create a do-it-yourself therapeutic milieu, be sure it’s safe. That’s why abusing your children, fighting with your spouse, arguing with your friends, yelling at your employees, or shaming your parishioners is not a good idea. It doesn’t bring out the best in anyone. It’s far better to make them feel safe. But don’t go overboard with safety, otherwise they’ll think they’re in a maximum-security prison.

Maximum-security prisons have so many things to ensure safety that it backfires. Cells with bars and guards with guns do not make your people feel safe. Far from it. They make people so wary, that any little thing will set them off.

Space
There’s a better way than cells and guns to create a sense of safety. You can give people space. We weren’t all in one room in our treatment program, so there was always an area folks could go if they didn’t like someone or needed a place to retreat. Some used it more than others. I had one client who would hang out in a stall in the men’s room all day long because he couldn’t tolerate people. The men’s room stall was all the therapeutic milieu he could take. Good thing we had it, or he would have found our milieu entirely untherapeutic. I used to sit in the adjacent stall and have my sessions with him through the divider, often trying to gently coax him out.  None of this was optimal for me, but I understood the need for space.

Even more important than having physical space was the space we gave to people to be themselves, with all their eccentricities. We did not insist on mindless conformity. Therefore, if you wanted to spend all day hiding from everyone in the men’s room, that was OK. It was also OK to come out of the men’s room sometime and join us.

If your home, club, workplace, or church has physical space to spare, then give people access and they will use it when they need it. Otherwise, you’ll have to create a sense of space by averting your gaze and permitting a friendly silence, but mostly by letting people be who they are, in their way.

Homeyness
The next component of a therapeutic environment is difficult to define. Homeyness is cozy and comfortable, snug and intimate, friendly and familiar. You know it when you see it. Maximum-security prisons aren’t very homey, to their detriment. We tried to make our program feel homey by having art on the walls, healthy plants, carpeted floors, and fabric on the chairs. It would have been nice to add non-florescent lighting, windows overlooking nature, and the smell of fresh-baked bread; but those weren’t in the budget.

Homeyness seems to be something desired by everyone, even when they haven’t had great experiences at home. I think it represents an ideal environment that feels comfortable and, yes, therapeutic.

Homeyness will probably be the easiest component that you can ensure in your therapeutic environment. After all, you are raising your kids, having your marriage, and seeing your friends in your home. This is harder in a hospital where there are standards of cleanliness, or in a workplace where there is work to do, or a church, where there are standards of comportment. But, in all cases, there may be things you can do to make your setting more homey and relaxed.

Reliability
We had a consistent schedule in our program that helped to make it therapeutic. A schedule tells folks what to do at any particular time so that, if there’s something they want to be a part of, they don’t miss it; and, if they don’t want to be part of it, they can avoid it. It also can fill the time that otherwise might be spent on rumination or acting out.

You can bring reliability to your home, club, workplace, or church by having a routine and starting things on time. Do the things you said you would do, and you will be known as reliable.

Membership
It’s not enough just to designate a room or two for your therapeutic milieu and fill it with people; they also must feel that they belong.

In our program, we fostered a sense of belonging by paying attention to one of the most crucial parts of our building: the door. We wouldn’t open the door and let just anyone walk in, they had to pass the watchful eye of a receptionist who would stop them if they did not belong. If you were new, you had to be screened, attend an orientation, be shown around and introduced. If you did all that for three days, then you belonged.

We also paid attention to whether folks have not passed through our door for a while. If they were missing, we called or visited to see if they were all right. If they didn’t come back, we used the door to shut it on them. That sounds mean, but we did it to protect the safety and integrity of the therapeutic milieu. They would need to go through the screening, orientation, and so on, before they could rejoin.

Doors and walls are not the only way to create membership, however. Another way to do it is by having a single focal point that brings everyone together. They should feel they have something in common with the other folks there. The bond is strengthened when they members are a minority, persecuted in the larger society, as was the case with our mentally ill and drug addicts.

In our program, we tried to do things that interested people and developed a common purpose, that of improving the mental health of our members. We also had a weekly community meeting where we made announcements, discussed program concerns, and formally introduced newcomers.

If you want to make your home, club, workplace, or church therapeutic, you may want to take a look at how you establish and maintain boundaries. Courtship has a series of challenges to pass through and marriage has a ceremony, of course, called a wedding. Then marriage is sustained by paying attention to the sanctity of it. You honor your commitment and don’t bad mouth your spouse to outsiders. Marriage should also have a common purpose, something you do together like raising children or maintaining a household.

It’s often interesting to see how families, workplaces, and churches manage membership. You are born or adopted into your birth family and there is often a ceremony that marks that occasion. But take a look at what your family, friend group, workplace, or church does when outsiders enter. Therapeutic milieus allow for a kind of provisional membership until the newcomer is accepted into the fold and then afforded all the rights, privileges, and duties expected of those born into it. Regular meetings, where the personal significance of each member is affirmed, is a feature of every therapeutic milieu. Family dinners, staff meetings, and worship services can serve this purpose if they capture the interest and show respect to members.

Understanding
So far, I’ve described a way of making a milieu therapeutic by describing how to use doors, walls, clocks, interior decoration, and activities to create safety, space, hominess, reliability, and membership.  This next ingredient cannot be supplied by arranging the furniture. For a milieu to be therapeutic, not only must the members enter a physical space; if you are the manager of the milieu, you also must let them into your head.

This means you must know everyone, be able to tell what they are doing, and understand what makes them click. And they must know that you know, see, and understand them.

Some people have tried to force this by creating in their milieu what’s called a panopticon. In a panopticon, the managers of the milieu can watch the people, they know they’re being watched, but they never know when they’re being watched. This is supposed to keep them honest and behaving better. The original panopticon was a prison, specially constructed that way; but you can say that a great deal of our present-day public and commercial space is a panopticon. There are cameras everywhere, even watching the watchers.

In our clinic, cameras were not in the budget, but people spent all day, every day there; so, we could see what they did. For the drug addicts, we used urine drug screens to extend our surveillance system into their evenings and weekends. We were careful to make our requests for urine random and unpredictable. This meant that, whenever they thought of using drugs, they’d also have to think they might get caught. This kept a lot of people clean and sober.

If this sounds a little creepy, that’s because it is. Surveillance can backfire if you take it too far. People generally find a way to do what they want to do, regardless of your cameras. Some people may have a greater urge to defy you out of spite. The people in our program were under the watchful gaze of our panopticon only when they were new or not doing well. As they progressed, they wouldn’t have to come every day and the urine screens would be less frequent. When we learned a person could be trusted, we trusted.

If you want your marriage to be a marriage which brings out the best in both of you, you must know your partner and have a good map of the inside of her head. Spend time with him, ask him about his day, and go to his work events. You can also track his movements with your phone, but that’s likely to backfire. Learn to trust by seeing he’s trustworthy.

If you’re going to be a parent and make your family a therapeutic milieu, grow some eyes in the back of your head. Know where your children are, meet their teachers, be friendly with their friends. But, as they mature, give them space and don’t read their diaries.

If you’re an employer, observe your employees at their work. Collect satisfaction surveys from their customers and investigate sexual harassment complaints. But when you start monitoring every keystroke, dogging their every step, and make them fill out a dozen forms justifying every expense, you risk pissing them off and making them paranoid. They’ll swipe your post it notes every chance they get.

Similarly, you should notice when a friend needs you and you should be there for him. A pastor should attend to the spiritual health of his flock. But, when you get all up in your friend’s shit, you’re just annoying; and a pastor who regulates everything about his congregation is the head of a cult.

Managing a therapeutic milieu is all about having the pulse of your people. Ensure safety, but not to the point where they fear you. Make them comfortable, be reliable, give them space, show them they matter, and pay attention. You can control these factors to create a therapeutic milieu, but don’t attempt to control the people.