Milieu Therapy: Building A Community To Fight Substance Abuse

Last Updated: July 6, 2020

Authored by Dr. Ahmed Zayed

Reviewed by Michael Espelin APRN

Milieu definition constitutes a social environment as translated in English. The actual milieu meaning in the French language is “middle.” Milieu therapy is based on the premise that changing the environment of a person can trigger positive changes. Therapeutic milieu takes place in communities of recovering addicts, usually inside residential treatment facilities. It helps them develop interpersonal skills and inner strength. The therapy also encourages self-care. Milieu therapists believe that the role of the therapeutic community during residential treatment is beneficial for people with substance abuse disorders.

Therapeutic Milieu Approach In Treating Substance Abuse

The background of therapeutic milieu can be traced back as early as the 1700s when a new approach to psychiatric care comprising moral treatment was initialized. Later in the 1800s and 1900s, there were several fluctuations in the hospital atmosphere and services offered at psychiatric institutions with milieu therapy originating in 1948.

In any chemical dependence treatment program, the milieu environment ensures that the complete experience at the rehabilitation center is therapeutic. Based on this study about the effectiveness of milieu therapy for mentally ill patients, it was concluded that the therapy proves effective for such patients as well.

Principles Of Milieu Therapy

people listening about milieu therapy

Milieu therapy is based on the following principles:

  • Mutual respect for clients and staff members is of utmost importance and needs to be upheld.
  • Effective communication between the clients and staff members is promoted to ensure they benefit from the therapeutic environment.
  • Patients are empowered to become autonomous and boost their self-esteem.
  • Patients are provided with opportunities to be part of milieu management during their stay.
  • Social interactions among clients are promoted so that they can learn from each other’s behaviors.
  • Rules and regulations are imposed, and everyone is held responsible for their actions accordingly.
  • Clients live and work as a team.
  • For clients struggling with the environment and regulations, group discussions and secluded time are enforced to help them readjust with the social milieu setting.
  • The milieu staff and nurses are responsible for enforcing these principles.

Characteristics Of Milieu Therapy

The characteristics of milieu therapy revolve around the concepts of empowering clients to become autonomous, independent, and responsible individuals as part of their long-term treatment plan. This is achieved through the following strategies:

The Community Is The Key Agent Of Change

The community includes professional milieu staff and addicts going through the recovery process. They regard every interaction as a chance for therapeutic action and peer influence. As a result, this can be a powerful catalyst for change. The therapeutic milieu community also creates a safe, supportive environment. This is where a person can go about the changing process without fears, holdbacks, and distractions. Based on this study about contemporary milieu therapy, the milieu is considered a therapeutic agent that exceeds and supports the staff’s individual efforts to intervene therapeutically.

Happy diverse people in milieu community

Reliance On Self-Help

Milieu therapy hinges on the active participation of the person. Patients are expected to take charge of their recovery. In particular, it results in responsibility for their behavior. Self-help is critical for independent living, building self-esteem, and the feeling of control of one’s life.

Varying Levels of Clients Needs

Therapeutic milieu expects people in recovery to contribute to the upkeep of their environment according to their developmental needs. The environment is also adapted according to these varying needs. Patients are divided into small groups of a similar level of needs. Clients who are in the initial stages of milieu treatment need more support and structure in the environment. In contrast, advanced clients can benefit from an environment where they are held autonomous and responsible.

Family Involvement And Communication

For this reason, milieu therapy usually takes place in a sober home or at an outpatient treatment facility where the clients can go about their other activities also. Family and community involvement is also encouraged through interactions, meetings, and communication.

Individualized Treatment Plans

The success of a milieu treatment approach rests much on each unique treatment plan. They expect each person to take charge of their treatment. Therefore, they must go through processes and procedures they are comfortable with. Each client is provided with all the information regarding their treatment, and individualized goals are defined. With the help of open communication, honesty, and mutual respect between the staff and clients, everyone works towards achieving those goals.

Key Concepts Of Milieu Therapy

milieu people gesture hand high five

Milieu Therapy comprises certain key concepts which are described below:

  • A milieu setting provides a safe, secure, and well-contained environment where clients are provided with all the basic necessities of life. They are assured that no one is there to judge them, and they feel safe from the social stigma attached to them in the outside world. A comfortable and supportive environment is provided where they are fully involved with their family members and the community. A healthy staff-client relationship is maintained where the clients are involved in all the decisions regarding their treatment.
  • Clients and milieu staff members are encouraged to show mutual respect. Each person is treated as an honorable individual, keeping in view all of their rights. This helps boost self-esteem in the patients, and they feel as important members of the community with their individuality.
  • Patients are offered opportunities for interactions with each other. This is carried out in a structured manner with rules and regulations imposed so that everyone knows the boundaries they have to respect during these interactions.
  • Patients are also offered opportunities to communicate with the staff in milieu settings effectively. A confidential communication agreement between the clients and the staff helps the clients feel safe. Through support, attention, and praise, the staff members can boost the clients’ confidence and help them in their journey towards recovery.

Milieu Therapy Techniques

In milieu therapy, positive change takes place in the community. To achieve these changes, the following milieu therapy techniques are usually applied:

  • Community support
  • Peer role modeling (setting an example to emulate)
  • Social learning (teaching interpersonal and functioning skills important for a socialized living)
  • Psychiatric support (managing or treating co-morbid mental health disorders and other disruptive disorders)
  • Remedial education (Educating the person about the condition and healthier coping strategies)
  • Family counseling (Helping family members support their loved ones on the journey to recovery)

Diverse people building milieu environment

Progressive Levels Of Responsibility in Milieu Therapy

The therapeutic milieu in mental health settings creates a structure that provides a stepwise increase in the responsibility of the clients based on their self-care capacity. In such a structure, four different levels can be defined:

Level 1

This level is characterized by patients who show destructive behavior either to themselves or to others. They do not seem comfortable in group therapy and feel confused about the time, place, and other people. They also have a hard time caring for their hygiene and appear disoriented.

Level 2

At this level of milieu therapy, clients do not show any destructive behaviors and practice good personal hygiene. They are also able to attend group meetings without feeling confused.

Level 3

In this relatively advanced level, a patient acknowledges his individuality and responsibility. They attend all therapeutic sessions and meetings. They also have regular interactions with family members, as well.

Level 4

The patients at the lower level are assisted in the concentration of their physical and safety needs. The higher-level clients focus on their self-esteem, social interactions, and self-actualization needs. Depending on the clients’ performances and adaptability, they advance to higher levels and take part in the fulfillment of different types of requirements.

helping new member to enroll in therapeutic milieu

Pros And Cons Of Milieu Therapy

Just like any other therapy or treatment program, milieu therapy might not be for everyone. It has its advantages and disadvantages which need to be weighed to assess the therapy’s effectiveness.

Sr. No. Advantages Disadvantages
1. Milieu environment is quite different from a hospital setting, so patients feel at home, which aides their recovery. The number of staff members is quite low as compared to the number of patients, which can become an issue.
2. Patients are able to contribute towards the decisions regarding their treatment and help fellow patients, which helps them feel less of a patient and dependant themselves. Since patients are divided into groups and assigned responsibilities, it may not reflect how well each patient in the group went about with the responsibility since the outcome is measured at a group level, not at an individual level.
3. Patients can interact and communicate with other fellow patients to develop friendly and supportive relationships. Because of the increased role of patients in their treatment plans, the responsibilities of the staff and patients might clash.
4. The power that patients have in making their own decisions regarding treatment helps in increasing their confidence. Because of the group settings, the individual needs of patients may not be met entirely.
5. Patients are able to develop leadership skills and present themselves as role models. In a collective environment of patients, conflicts might arise, which the staff should be trained to handle.
6. Patients learn to co-exist with other fellow patients and members of the community, which helps them develop good interpersonal skills. If a continuous communication channel is not established among the staff and clients, it can result in negative outcomes.
7. Patients can let their negative attitudes and behaviors go in order to adopt socially acceptable behaviors. Although a milieu setting is less rigid than a hospital setting, patients still might have a hard time to adjust back into society.
8. A milieu environment focuses on a stress-free and nurturing atmosphere, which helps patients to change their way of thinking and make it more positive. Milieu therapy is not available to clients who are not part of a sober home or an outpatient treatment program.

Using Milieu Therapy For Successful Recovery

Milieu therapy can be successfully used during the treatment of substance abuse disorders and other co-occurring disorders. When this therapy is combined with other evidence-based therapies such as behavioral therapies and experiential family therapy techniques, it can result in a great success rate. Different programs within the milieu treatment incorporate different strategies and techniques that contribute towards the success of patients in recovery. These programs are:

  • Client Government: This milieu treatment program includes several structured meetings that are held regularly every week. Patients are given the authority to voice their opinions and inputs into all the related activities. Clients are also encouraged to discuss any problems that they might be facing.
  • Work-Related Activities: Clients are encouraged to take part in various work-related activities. Whatever they want to do, it is their choice. This constitutes work therapy through which patients learn and develop specific skills through a variety of activities. Patients are also offered monetary rewards for successful completion of work activities.

Page Sources

  1. Yvonne Smith, Matthew C. Spitzmueller, Worker Perspectives On Contemporary Milieu Therapy: A Cross-Site Ethnographic Stud, 2016,
  2. Betty Hunt Bradley, Ruth Maurer, Marcel Hundziak, A Study of the Effectiveness of Milieu Therapy and Language Training for the Mentally Retarded,

Published on: March 29th, 2017

Updated on: July 6th, 2020

About Author

Dr. Ahmed Zayed

Dr. Ahmed Zayed is a Bachelor of Medicine and Surgery. He is graduated from the University of Alexandria, Egypt. Dr. Ahmed Zayed has a passion for writing medical and health care articles and focuses on providing engaging and trustworthy information to readers.

Medically Reviewed by

Michael Espelin APRN

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care.  He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.


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  • Peter C
    As a Milieu therapist myself I thoroughly enjoyed your detailed definition of my profession. Please dont hesitate to ask me anything pertaing to M.T.