Worker Perspectives on Contemporary Milieu Therapy: A Cross-Site Ethnographic Study of Mental Health Practice
The term “milieu therapy” (MT) is commonly used in direct practice literatures. However, because MT models historically have encompassed a wide range of practices, they have invited the criticism that MT is little more than the attractive theoretical packaging of the time clients spend between specified interventions. Some have suggested that, because of its conceptual ambiguity, MT should be abandoned altogether (e.g., Delaney, 1997). Nevertheless, despite significant challenges, MT endures as a common modality of social work practice. Weissman et al. (2006) find that 43% of social work programs offer didactic training in MT and slightly more offer clinical supervision in MT. The present study uses ethnographic methods to investigate two organizations that provide MT. This study brings empirical findings to bear on the question of how contemporary mental health workers understand what it means to work “in the milieu.”
Methods
This presentation reports findings from two yearlong ethnographic studies of milieu-based mental health programs. The first site was an urban “drop-in” center for adults with serious mental illness. 73 informal interviews and 28 semi-structured interviews were conducted concurrently with 1300 hours of direct observation of the day-to-day routines of 45 consenting mental health workers. The second site was a residential treatment program for children and adolescents with serious emotional disturbance. 35 semi-structured interviews were conducted concurrently with 1500 hours of participant-observation of day-to-day activities of 78 consenting workers. In the iterative process of ethnographic theory-building, tentative themes were developed through participant observation and refined through repeated interviews with key informants. Themes were then compared across sites to develop an account of how workers understand MT.
Results
Workers at both sites identified a common set of themes. The therapeutic milieu was characterized as a physical and social setting in which every action and feature of the environment shapes the behavior and affect of clients. Workers described the milieu as a supportive social environment where workers model adaptive social behaviors and where individuals with mental illnesses can “practice” healthy behaviors that they can then apply in their “natural communities.” Workers often attributed clients’ progress to the influence of the milieu itself rather than to particular interventions carried out within it. Workers experienced this immersive and putatively therapeutic setting in which “everything is clinical” as an opportunity for accelerated professional learning through observation of clients and experienced colleagues.
Conclusion and Implications
This study suggests that—despite claims to the contrary—several clear principles appear to underlie milieu-based practice. These findings contest the idea that MT is a diffuse catchall phrase that denotes no specific set of practices or theories. While more research is needed in this area, these findings, which delineate both workers’ understandings of MT and their perceptions of its active ingredients, are relevant to attempts to specify MT as a reimbursable intervention. Finally, this study identifies key elements of contemporary MT that may be usefully addressed in social work curricula and to the potential value of MT-based field experiences.