Milieu therapy
Milieu therapy is a term from psychiatry and social psychology , goes back to the psychiatrist and psychoanalyst Wilfred Bion and means: Common therapeutic process within the framework of a temporary community.
Milieu therapy in psychotherapy and psychiatry
Main article: Therapeutic community
Milieu therapy
Milieu therapy designs the institution as a so-called artificial family and also uses it therapeutically. Depending on the patient, the milieu is structured, balancing, animating, reflective or caring. A typical form of organization in an addiction clinic is: a social worker as the leader of the team, two other social workers, a psychologist, a doctor, a teacher, a cook and a person responsible for the house. Together with the residents, they form a framework with protective boundaries: house rules for the groups, a structured daily and weekly schedule, participation in certain group activities and taking on domestic services. Caregivers and residents are equally involved.
Milieu therapy according to Bruno Bettelheim
In 1944, Bettelheim founded the Sonia Shankman Orthogenetic School on the campus of the University of Chicago with the support of Dean Ralph W. Tyler. "The school", as he used to call this facility, was a youth psychiatric home for full inpatient admission of 34 children aged six to twelve years. Both the name and the psychotherapeutic concept, however, differed greatly from the treatment and care methods of the time.
Milieu therapy instead of analytical psychotherapy
At that time, psychotherapy was primarily understood as the analytical therapy according to Freud, whose pupil Bettelheim had been in Vienna. Bettelheim did not find it helpful for the severely emotionally disturbed children to recreate conflictual situations in therapeutic sessions in order to be able to work through them on a purely verbal level. Under the term milieu therapy, he developed a holistic concept in which no distinction was made between everyday care (social therapy) and psychotherapeutic sessions. In five (sleeping) groups, each led by a teacher and two to three supervisors, they accompanied the children throughout the day. Since the children being looked after had had negative experiences with the world of adults to a large extent, the carers held back with their direct involvement and initially made sure that the children could integrate into the respective group. The different characters of the supervisors and groups offered the necessary diversity to provide the appropriate environment for every form of disorder.
Building trust instead of intervention
In order to create a basis of trust in the child's massively disturbed world of relationships, the carers initially limited themselves to satisfying the children's material wishes. The daily routine was clearly and uniformly regulated for all groups, but no child was forced to do anything. On the contrary, the carers kept asking the children to express their needs. On the one hand there was a clear daily structure with three main meals and two snacks at fixed times and on the other hand the possibility of getting as much milk and bread and butter as desired at any time. There was also school hours from 9 a.m. to 12 p.m. and from 1.30 p.m. to 3 p.m., but no obligation to attend classes on time. If it met a child's momentary needs, they could spend the whole day in bed. This markedly submissive attitude on the part of the teachers and carers served to convince the child that he was surrounded by adults who were interested in the children and did not want them involved in well-known power games. Once the child was assured of their benevolent surroundings, they could begin to form relationships with the adults they had a natural attraction to.
Play hours as a psychotherapeutic session
In order to expand the children's field of experimentation, there were additional play lessons in which the child could interact with a psychiatrist in individual sessions. According to the concept described above, participation was voluntary and the initiation process itself was usually a trust experiment. The aim of this offer was to offer the child an additional level of relationship that was outside the daily structure. In this way, the child was given the opportunity to tackle conflicts that he or she may not yet dare to address with their direct caregivers.
School as a forum for curiosity
The six school groups were not put together according to age, but in such a way that they enabled the children to belong individually to their needs and limitations. As soon as there was a basis of trust between the child and the teacher, the teacher's attention, who was also available for the rest of the day in the sleeping groups, was directed to dealing with the learning inhibition. The student's cooperation and commitment was therefore exclusively on a voluntary basis. In order to make the child experience that the teacher was concerned about the child's well-being, he prepared individual tasks for each child and supported them in their elaboration. Only when the child had worked through their worst needs and compulsions as part of the overall therapeutic process could they be interested in things within the world. The teacher was able to use this interest, which sometimes emerged for the first time, to provide the child with knowledge on the relevant topic. According to Bettelheim, many children were able to make up for their knowledge deficits quickly after they began to show their own interest in school lessons. This very individual pedagogy had no uniform curricula that were based on age requirements. If a child changed his learning behavior seriously due to the therapeutic process, the other five school groups offered the opportunity to change teachers and subject. Bettelheim emphasized that the child's growing interest in the world is an important key to their education, but that it must be used to enable the child to experience experiences that can help them to discover and develop their individual abilities and strengths.
Transparency and spontaneity
The form of milieu therapy presented above corresponds to an idealized form, according to Bettelheim. Since the teachers, supervisors and Bettelheim felt themselves to be learners and experimenters, but also as teachers, there were daily meetings, super and intervision groups in which the children did not take part. The declared aim was to understand the children better and to be able to respond to them better. The conversations about the children were recorded regularly. Bettelheim emphasizes that these records should remain free of personal interpretations of the children and should only be used for spontaneous affection and actions. They should be written with the children in mind that they will better understand and explore. It is therefore not surprising that the children had full access to these documents upon request and with the involvement of an adult. In order to create the appropriate milieu, all those activities were planned in these discussion groups that were designed to offer the children a supportive environment. This should be designed in such a way that it enables the child to cope with gradually more difficult tasks and thus to make progress in his personal development in the natural course of the day. These advances should be made out of respect for the performance of the individual child and not the ability to assert oneself in a hostile act against another child. A group is prepared to pay this respect insofar as it has experienced that its basic needs are unconditionally satisfied.
Space and time as I-coordinates
As already described above, Bettelheim describes milieu therapy as a holistic concept that does not allow any functional division into different areas of life or therapy. Bettelheim emphasizes that even for Freud there was an affinity between a certain external milieu and the willingness of the person concerned to do certain experiments in it. However, he was unable to make any well-founded statements, as sufficient scientific studies were not yet available. However, what Bettelheim shows as an example is the observance of the spaces and times. He observed that children choose spaces such as corridors, broom closets, cloakrooms and stairwells in order to try special experiments in which a strong ego concept of the child comes into play. He explained this by saying that all other rooms that were consciously designed by adults for a specific functional activity (dining room, bedroom, office) would restrict the child's imagination. He observed the same for split times. By this he meant uncertain waiting rooms for the children, where the previous activity had stopped but the new one (transition between school and lunch time) had not yet started. Especially in these time intervals, the children need special attention, because the self-creation of these intervals requires special ego stability of the children. From these observations it becomes clear that a distinction between therapeutic intervention and everyday life is not very useful for understanding and supporting children. The specific effects of the respective place or the respective point in time are the outstanding coordinates for the appropriate attention of the child.
Therapeutic milieu
The "therapeutic milieu" was developed by Fritz Redl in the clinical-psychiatric field and implemented in 1953 in the children's ward in a large psychiatric hospital in Bethesda. The basis was Redl's "educational-therapeutic concept", which he introduced in 1946 in the "Pioneer House", a small reformatory in a slum in Detroit.
Redl described 7 characteristics for "Therapeutic" and 12 characteristics for "Milieu":
| Therapeutically | milieu |
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Therapeutic community
The therapeutic community , described by Sigmund Foulkes , is on the one hand a therapeutic field: the entirety of all therapeutic forces working in a hospital. At the same time, it is the community of all patients who support each other in their therapy process. A therapeutic community is a temporary community. People with similar problems decide to use the power of the community to "treat" one another under the guidance of experts.
literature
- August Aichhorn : Neglected youth - psychoanalysis in welfare education . 1951, ISBN 978-3-456-84260-8 .
- Bruno Bettelheim : Love alone is not enough . 1971, ISBN 978-3-608-91879-3 .
- Edgar Heim : Practice of Milieu Therapy . 1985, ISBN 978-3-540-13571-5 .
- Bernd Otto: Bruno Bettelheim's milieu therapy . 1993, ISBN 3-89271-387-1 .
- Fritz Redl : Raising difficult children . 1987, ISBN 3-492-10664-1 .
- Donald W. Winnicott : Maturation Processes and Enhancing Environment . 1974, ISBN 3-463-00602-2 .
Milieu therapy in geriatrics
In geriatrics, milieu therapy means the adaptation of the material and social environment to the changed perception, sensation and competence of demented patients.
theory
In milieu therapy, it is assumed that with age, in general, and especially with people with dementia, environmental competence continuously decreases. A person needs environmental competence in order to find their way around in their environment. On the other hand, there are the environmental requirements, which make it increasingly difficult for demented patients to find their way around in their environment. Normally, environmental competence and environmental requirements are in a balance, which gives people a high degree of independence and life satisfaction. If this balance is thrown out of balance due to dementia or old age, this can be remedied by promoting resources or by adapting the environment to the environmental competence of people. In the case of people with dementia, the extraction of resources is only possible to a limited extent, so the environmental requirements are adapted to the environmental skills. This adaptation takes place via the reduction of sources of excessive demands and the radiance of security and security.
Milieu therapy consists of three core elements:
Social environment
The caregiver should develop a personal relationship with the patient in order to be available as a caregiver for the person with dementia. For this purpose, the caregiver should approach the demented person like any other person with respect , acceptance, confirmation and partnership. The communication over the demented man should be adapted so as not to overwhelm him. The patient should be addressed in clear and short sentences, but also through touch and eye contact. The previous social environment should also be included in dealing with, so as not to cause a break with the previous life. In order to make these requirements easier for the carer, the concept also includes the working atmosphere. The following applies here: Increase job satisfaction in order to make it easier for the carer to care for.
Daily structuring
Due to the disturbed time and location orientation, a firmly structured daily routine should be introduced for people with dementia. Every day here should be structured in the same way to give a feeling of security. Phases of activity and rest should alternate in the daily routine. In the activity phases, the patient should be given a task that is neither too demanding nor too demanding. If possible, the patient should be active in a group in order to prevent the feeling of social isolation.
Architectural environment
The spatial environment should offer both protection and the possibility of activation. This is done through open and manageable rooms that promote interpersonal contact. Furthermore, the open spaces should not set any limits to the urge to move in demented patients. Circuits or endless corridors are ideal for exercising the urge to move. If possible, the furnishings should come from the patient's previous apartment in order to give them a feeling of being at home through familiar furniture or pictures. To make it easier to orientate yourself in time, a bright environment should be guaranteed during the day. Furthermore, the environment should be quiet in order not to expose the patient to excessive levels of stimuli. The activity of the residents is encouraged by offering employment opportunities. This is done, for example, via open and freely accessible shelves or cupboards that the resident can help himself to.
literature
- Swen Staack: Milieu therapy: A concept for the care of people with dementia . Vincentz-Verlag Hannover 2004, ISBN 978-3-87870-118-7 .