"The fundamental premise of any therapeutic milieu is the sharing of power between all members of the community. A therapeutic community is not a static piece of equipment but a way of relating and communicating - never easy, never automatic, always in danger of succumbing to administrative convenience. David Kennard, 1998, Introduction to Therapeutic Communities 
The events of the first half of the twentieth century shook many fundamental systems of meaning, particularly the relationship between the individual and the community. Psychiatrists who showed a willingness to confront these issues at home, after the war, called themselves social psychiatrists. They were often to be found working in milieu settings that were quite different from the traditional psychotherapeutic setting and the traditional psychiatric hospital. Psychoanalytic psychotherapy and all its offshoots were grounded in an approach to the patient that focused almost exclusively on the individual. The relational aspects of therapy were implicit in the relationship between therapist and patient, but the main source of problem and motivation for change was seen as being intrapsychic - within the individual. The social and political contexts were not relevant and were largely disregarded. Sarason observed in 1981, that “. . . the theories generated by these studies [psychological research studies] have been, for all practical purposes, asocial. That is to say, it is as though society does not exist for the psychologist. Society is a vague, amorphous background that can be disregarded in one’s efforts to fathom the laws of behavior” .
The therapeutic community - or milieu - concept was one attempt to apply the tenets of social psychiatry and systems theory to the institutional treatment of various kinds of deviance. The hospital was seen as being a microcosm of the larger society, an experimental laboratory for social change .
One of the most interesting aspects of this development was the widespread use of group forms of therapies. Faced with the need for intensive treatment of combatants during the war with limited resources, military psychiatrists developed group forms of treatment that had been extremely helpful in treating battle-fatigued soldiers. In England, J. R. Rees who was the director of the Tavistock Clinic, was appointed consultant psychiatrist to the army in 1938. In this capacity, he and his team were led to consider the far-ranging implications and problems of psychiatric work in wartime. Their focus shifted from the individual to the larger problems of group relations [4-8].
Meanwhile, the British army set up a treatment unit at Northfield Hospital under the leadership of Tom Main, who originated the concept of the “therapeutic community.” In a paper published in 1946, Main wrote, “The fact must be faced that radical individual psychotherapy is not a practicable proposition for the huge numbers of patients confronting the psychiatric world today. . . The Northfield Experiment is an attempt to use a hospital not as an organization run by doctors in the interests of their own greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the neurotic individual for life in ordinary society” .
During the same era in the United States, Harry Wilmer, a psychiatrist stationed at the Oakland Naval Hospital, used his own experience as a patient in a tuberculosis sanitarium at the beginning of World War II to create a program based on group therapy for returning veterans. His experience was similar to that of his British colleagues.
He refused to use any control other than social control, and the staff were taught to establish the firm expectation that the patients could and would control themselves. This required the staff to learn ways of managing difficult patients without using the usual forms of external control - seclusion, restraint, and punishment. The result was that many patients who had been hostile, belligerent, and assaultive in other settings were treated in the therapeutic milieu without resorting to violence. “I never found it necessary to isolate even one of the 939 patients with whom we dealt, despite the fact that almost every type of acute psychiatric disorder was represented in the group. This result was achieved largely because the staff, no longer free to use methods of control that brutalize both themselves and their patients, had to find new ways of dealing with patients. They found the new ways more effective and infinitely pleasanter than the old” .
It was Maxwell Jones who most enthusiastically developed the concepts of the therapeutic community both in Britain and in the United States and attempted to spread those concepts to institutions outside of the formal psychiatric system. Another army psychiatrist, Jones first developed a program during the war to treat soldiers suffering from “effort syndrome,” a psychosomatic disorder that was related to combat fatigue. The approach was focused on education in a group setting which led to the development of a “group atmosphere”. Treatment was no longer confined to a therapeutic hour but became a continuous process operating throughout the waking life of the patient. To accomplish this, Jones had to reorder the hospital society and flatten the traditional hierarchical pyramid of authority to promote more interaction between patients, nurses, and doctors. Even before Moreno’s techniques about the use of dramatic techniques as a form of treatment had become well known, Jones was using drama as an effective technique of social therapy . The patient would write, direct, and act in his or her own personal play with the help of the entire community, as part of an intensive therapeutic experience.
After the war, Jones developed a program for ex-prisoners of war and continued experimenting with the use of discussion groups, educational films, psychodrama, and discussions of community life. The results of the work impressed the government enough to ensure the development of a postwar program at Belmont Hospital to treat the chronically unemployed neurotic. Patients who were admitted were those considered unsuitable for either psychotherapy or physical methods of treatment such as electroshock, but excluded psychotic patients. He described the treatment population as "Inadequate and aggressive psychopaths, schizoid personalities, early schizophrenics, various drug addictions, sexual perversions, and the chronic forms of psychoneuroses. Our patients represent the 'failures' in society; they come largely from broken homes and are unemployed; inevitably they have developed antisocial attitudes in an attempt to defend themselves from what appears to them as a hostile environment; as often as not their marriages are in ruins and there is little or no attempt to keep up any of the more usual standards of behavior in their home life” . These were not the worried well, but severely dysfunctional, but non-psychotic patients. These same kind of patients today may wind up in the mental health system but are just as likely to constitute a large proportion of our growing prison population.
Jones and his colleagues performed follow-up studies and six months after leaving the hospital, two-thirds of the patients they traced had made a fair adjustment or better. Just over one-half had worked the full time since leaving. Patients generally stayed in the hospital for two to four months, but some patients stayed up to a year, while others stayed a much shorter time than two months. Jones based his work on the idea of “social learning, "The term social learning describes the little understood process of change which may result from the interpersonal interaction, when some conflict or crisis is analyzed in a group situation, using whatever psychodynamic skills are available. . . Learning of this kind is complicated and painful: old learned patterns, adequate in previous situations, must be unlearned because they stand in the way of acquiring new and more adequate patterns of behavior." . To his way of thinking and working, every social interaction or crisis presented a “living-learning situation,which provided the grist for the therapeutic mill and the opportunity for changing and learning how to change.
Under the influence of Jones, Main, Wilmer and others [13-14], combined with the publications of critiques of the existing mental health system [15-16] and the sociopolitical influences that permeated the psychiatric world, the concept of the therapeutic community and its attenuated form - the therapeutic milieu - caught on in Britain and the United States and dominated the field of inpatient psychiatry throughout the 1960’s, presenting a potent challenge to the traditional organization and modus operandi of state hospitals .
The most striking characteristic of the therapeutic milieu was that the community itself - and all the individuals who constituted it - were the most powerful influence on treatment. Unlike many other settings, many of the values that formed the underpinnings for every milieu were clearly articulated-egalitarianism, permissiveness, honesty, openness, trust [14, 18-19].
All therapeutic communities rested on several assumptions: patients should be responsible for much of their own treatment; the running of the unit should be more democratic than authoritarian; patients were capable of helping each other; treatment was to be voluntary whenever possible, and restraint kept to a minimum; psychological methods of treatment were seen as preferable to physical methods of control. Psychotherapy, individual therapy, and various forms of group therapy were used routinely and were usually psychoanalytically informed [18, 20-21].
By 1969, Abroms was describing milieu therapy as a “treatment context rather than a specific technique . . . a metatherapy” . Tucker and Maxmen (1973) described the treatment milieu as a"laboratory wherein the patient may safely experiment with newly acquired adaptive skills” . The aim of a modified therapeutic community was to "promote a corrective emotional experience, enhance personal understanding, and maximize healthy ego growth" .
The therapeutic milieu concepts, as advocated by Jones and others, were powerful influences on many of us who trained in psychiatry during the 1970s. The tenets of the therapeutic community provided the foundation for our first attempts at creating a new community.
Excerpt from Bloom, S. L. (1997) Creating Sanctuary: Toward the Evolution of Sane Societies, 1997, 2013
Bloom, S. L. (2010) Chaos Theory and Therapeutic Community
Common Attributes of the Therapeutic Milieu
- Informal and communal atmosphere
- Central place of group meetings
- Sharing the work maintaining and running community
- Therapeutic role of patients/residents
- Sharing authority
- Values and beliefs
- “Feel” the difference immediately
- Communalism - more like a boisterous family
- Usually private events out in public
- Higher tolerance for expression of affect
- Marked expression of individuality
- Central place of group meetings
- Maximize the sharing of information
- Build a sense of cohesion and unity
- Make open and public the process of decision-making
- Provide a forum for feedback
- A vehicle for community pressure
- Sharing the work
- Work that contributes to the daily life of the community - not work to keep the patients busy
- Helps build the community
- Helps build an experience of social responsibility
- Provides laboratory for viewing patterns of interpersonal relationships
- Therapeutic Role of Patients
- Peer support
- Affect modulation
- Unique understanding
- Improved self-esteem
- Development of mutual respect
- Getting out of the “patient” role
- Sharing Authority
- Responsibility and authority
- Everyone sees themselves and each other as vital parts of the whole.
- Simultaneous development of social responsibility along with personal responsibility
Bloom, S. L. and Norton, K. (Eds) (2004) Special Section on The Therapeutic Community in the 21st Century. Psychiatric Quarterly 75 (3): 229-231
Haigh, R. & Tucker, S.(2004) Democratic Development Of Standards: The Community Of Communities—A Quality Network Of Therapeutic Communities. Psychiatric Quarterly 75(3): 263-277.
Kennard, D. (2004). The Therapeutic Community As An Adaptable Treatment Modality Across Different Settings. Psychiatric Quarterly 75(3): 295-307.
Lees, J., Manning, N., Rawling, B. (2004). A Culture of Enquiry: Research Evidence and the Therapeutic Community. Psychiatric Quarterly 75(3): 279-294
Norton, K. and Bloom, S. L. (2004). The Art And Challenges Of Long-Term And Short-Term Democratic Therapeutic Communities. In Special Section on the Therapeutic Community in the 21st Century. Psychiatric Quarterly 75(3): 249-261
Whitely, S. (2004). The Evolution of The Therapeutic Community. Psychiatric Quarterly 75(3): 233-248.
- Kennard, D., Introduction to Therapeutic Communities. 1998, London: Jessica Kingsley.
- Saraon, S.B., Psychology Misdirected. 1981, New York: Free Press.
- Tucker, G. and J. Maxmen, The practice of hospital psychiatry: A formulation. . American Journal of Psychiatry, 1973. 130: p. 887-891.
- Bion, W., A Memoir of the Future. 1991, London: Karnac Books.
- Foulkes, S.H. and G.S. Prince, Psychiatry in a Changing Society. 1969, London: Tavistock Publications.
- Foulkes, S.H., Therapeutic Group Analysis. NOTES AVAILABLE ed. 1964, London: George Allen & Unwin, Ltd.
- Manning, N., The Therapeutic Community Movement: Charisma and Routinization. 1989, London: Routledge.
- Rees, J.R., The Shaping of Psychiatry By War. 1945, New York: W. W. Norton.
- Main, T., The Ailment and Other Psychoanalytic Essays. NOTES AVAILABLE ed. 1989, London: Free Association Books.
- Wilmer, H., Social psychiatry in action: A therapeutic community. 1958, Springfield, IL: Charles C. Thomas.
- Jones, M., The Therapeutic Community: A New Treatment Method in Psychiatry. 1953, New York: Basic Books.
- Jones, M., Beyond the Therapeutic Community: Social Learning and Social Psychiatry. 1968, New Haven, CT: Yale University Press.
- Caudill, W., The Psychiatric Hospital as a Small Society. 1958, Cambridge, MA: Harvard University Press.
- Rapoport, R.N., Community as Doctor: New Perspectives on a Therapeutic Community. 1960, London: Tavistock Publications.
- Greenblatt, M., D.J. Levinson, and R.H. Williams, The Patient and the Mental Hospital. NOTES AVAILABLE ed. 1957, Glencoe, IL: The Free Press.
- Stanton, A.H. and M.S. Schwartz, The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment. 1954, New York: Basic Books.
- Grob, G.N., From Asylum to Community: Mental Health Policy in Modern America. 1991, Princeton, NJ: Princeton University Press.
- Almond, R., The Healing Community: Dynamics of the Therapeutic Milieu. 1974, New York: Jason Aronson.
- Leeman, C., The therapeutic milieu and its role in clinical management., in Inpatient Psychiatry: Diagnosis and Treatment, Second Edition., L. Sederer, Editor. 1986, Williams and Wilkins: New York.
- Cumming, J. and E. Cumming, Ego & Milieu: Theory and Practice of Environmental Therapy. 1962, New York: Aldine Publishing Company.
- Wilmer, H., Defining and understanding the therapeutic community Hospital and Community Psychiatry, 1981. 32: p. 95-99.
- Abroms, G.M., Defining milieu therapy. Archives of General Psychiatry,, 1969. 21: p. 553-560.