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Creating an Empathic Environment:
The Essentials of Integrative Milieu Treatment

By: Kevin McCready, Ph.D.

"To face the future freely, one must give up both optimism and pessimism and place all hope in human beings, not trust in tools." - Ivan Illich

The disease model of treatment is only only dominate but it is dominating. The inevitable end of regarding human suffering as a physical disease is to regard the purpose of treatment as being to control the suffering and any manifestations of it. Since suffering is an integral part of being human, the disease model therefore seek to control and suppress humanity.

Yet, the world is full of empathic therapists who ultimately yield to the pressures of biopsychiatry. It is not uncommon to hear therapists report that they always "try" examination of psychotropic drugs that goes beyond the superficial propaganda and psychotherapy before turning to drugs or that they only use drugs "when absolutely necessary." However, this is tantamount to abusive parents claiming that they only beat their children "when absolutely necessary."

Some therapists claim that drugs and therapy together are necessary to help people overcome suffering. This statement has a superficial appeal. However, any marketing of the biopsychiatric industries reveals that this statement is in fact, irrational. Psychotropic drugs work by impairing brain function and thus suppressing humanity and enhance empathy. These are not conditions that cultivate a person's humanity and enhance empathy. These are conditions that dehumanize.

Other therapists will insist that their hand is forced by the patients themselves who behave in such a self destructive or dangerous fashion that they need to be restrained and the therapist does not have the opportunity to even "try" psychotherapy. This can seem to be a compelling argument at first.

But the fallacy of this argument can be found easily, that is if one is willing to look. In the early 70's Phillip Zimbardo published the "Stanford Prison Experiment.' Zimbardo randomly divided his undergraduate psychology class into two sections. One half of the class were designated as "guards" the other half as "prisoners." He then converted the basement of the psychology building at Stanford University into a makeshift prison. Within hours both the guards and the prisoners adopted and acted out their designated roles with an ardor far beyond the class exercise. perhaps even more importantly Zimbardo noted that he himself lost his objectivity within days. That is, in spite of his intentions and considerable training Zimbardo soon became a product of his environment.

Likewise, the environmental milieu of so called mental health settings as well as the fundamental orientation philosophy will determine the behavior and interactions of the players to a much greater extent than one might imagine. Thus, the pronouncements should we be surprised when we reap what we have sown.

Obviously, a great deal of the "need" to restrain patients has its origins in the demand characteristics of the biopsychiatric treatment environment and the restrictive, reductionistic paradigm that underlies it.

It is absolutely imperative to realize that restraint is not treatment. Likewise a treatment paradigm founded on restraint must always default to restraint as its ultimate purpose. Again, this is not treatment, and it is certainly not in the service of the person's humanity.

No surgeon, no matter how skilled nor dedicated can operate successfully in a dirty room with the wrong tools. Likewise, no therapist can truly serve the needs for psychotherapy patients most in need of empathy and humanity in the climate of restriction and control that characterizes the biopsychiatric mental health community.

Paved with Psychotropics

Obviously, some of these arguments come from therapists who are cynically rationalizing their use of toxic or dehumanizing means to "help" their patients, But often even the most sincere therapists and clients find themselves confounded and confused as they proceed, albeit ambivalently, down the road of their good intentions.

Students and other therapists often acknowledge that they are frightened and intimidated. They have been exposed only to the medical or disease model offered by biopsychiatry. In a cult-like fashion alternative ways of thinking are not even mentioned - as if there is no alternative way to think. Both criticism and critical thinking are severely discouraged.

Students are told even by their professors in academic settings that it is unethical even that they may be sued for malpractice (the consummate "bogeyman") if they don't "recommend" (code for "persuade" or "coerce") that their patients take drugs. Some report that they have been told that it is immoral, even sadistic to withhold drugs from

patients. This latter claim is based on the assertion that drugs somehow keep people from suffering. But, like most brainwashing techniques the empty promises of the latest "Darling Drug" only exploit the fears, insecurities and self doubts of its victims both professional and patient. As C. S. Lewis' warned - " There is no tyranny so great as that which is practiced for the benefit of its victims.


Being and Nothingness in Therapy

Several years ago I sponsored a seminar conducted by Peter Breggin. One of the audience members worked in a psychiatric hospital. She stated that although she saw how destructive and abusive the system was she believed that she could be someone the patients could trust. "But, don't you see, you're only confusing them?" was Dr. Breggin's reply. "The patients will not trust their own instincts about how bad this system is. 'After all,' they may reason, 'a nice person like you certainly wouldn't work for a system that would hurt me!"'

She responded that she had to make a living. But again, Breggin very gently suggested that she would, in fact, be doing the world a whole lot more good by not working in such a system therapist!" Finally, she cried out, almost painfully, "But, want to be a therapist.

At hat point I was unable to contain myself any longer. From my perch on the side of the room shouted (as empathetically as I could) "But you are not BEING a therapist!"

How could she be?

In such oppressive if not sadistic environments as psychiatric hospitals it is not possible to "work with the system." This is a myth. Oppressive systems do not empower individuals who criticize their oppression. Any attempts to treat patients outside of the biopsychiatric paradigm are condemned and ridiculed. The offending therapist is often attacked both personally and professionally. Tragically, the patients of such therapists may be targeted for even more extreme abuse in a systemic retaliation that works to ensure the self-fulfilling prophecy of failure of any treatment that defies the biopsychiatry myths.

Get Along Uber Alles

I recall early in my career complaining to my supervisor (a psychologist, not a psychiatrist) that the hospital staff were mistreating my patient and sabotaging his progress. My supervisor agreed. He stated that this was a common problem but that if were to criticize the staff they would only escalate their abuse. He suggested that needed to learn before to work "with" the staff. commented that if this is the mentality of the program (i.e. the patients are to be sacrificed to serve the needs of the staff!) that it would be better to close the facility. He chuckled. I resigned shortly thereafter.

No, in order to treat patients empathetically, it is necessary to create an empathic environment. In order to truly relate to another human being in a genuinely empathic sense it is necessary to go beyond merely wishing to be empathic. One must strive to create an integrated, empathic environment in which both the patient and the therapist are not only surrounded but immersed in a systemic fashion such that human dignity and empathy are the rule not the exception.

How can psychotherapy professionals not inclined to drug and abuse their patients resist the siren call that promises to "fix" their patients and keep themselves "safe" at the same time?

Creating an Integrative Milieu:

For almost a decade, San Joaquin Psychotherapy center has offered a genuine alternative to the biopsychiatric or disease model of treatment for people suffering from emotional or psychological distress. This alternative model is called an "Integrative Milieu." "Integrative" because it seeks to value and integrate all aspects of the individual including the often disturbing but meaningful expressions of distress called If symptoms." "Milieu" because the primary focus of "treatment" is to create an environment that facilitates this integration These elements promote the inherent growth and healing functions of the human psyche. In contrast to the disease model of treatment the Integrated Milieu strives to expand the depth and breadth of a person's humanity to overcome distress and dysfunction rather than restriction of humanity through an attempt to control symptoms.

Located in the unlikely area of Fresno in California clients find this modest clinic from as far away as Venezuela and New Zealand. The center has been highly successful in treating clients without harmful psychiatric drugs and helping clients get off the dangerous psychiatric drugs they have been forced or coerced to take In almost ten years of treating patients some of whom have been labeled with the most severe psychiatric diagnoses and declared to be "untreatable" without from six to ten psychotropic drugs. There have been no suicides, no incidents of significant violence

and although there have been times when Other parties have intervened or interfered we have never returned a patient to a psychiatric hospital

According to the prevailing propaganda of biopsychiatry this can't be done.


Not How - Why: A different way of thinking yields different results

I am often asked: "How do you treat patients?" or "What do you do differently?" This is a difficult question to answer Not because I don't know what it is that we do differently. But in a materialistic, technique oriented culture it is so difficult to convey that what we do is derived not from a different method but from a different paradigm.

We do not so much "treat" or even "heal" patients. We create an environment in which they may heal. Please note the deliberate use of the word "may." One of the piliars on which this paradigm is based is that free will and personal responsibility are essential. I would go as far as to say that the devaluation of individual freedom and personal responsibility is one of the primary sources of iatrogenic problems in therapy.

Patients or family members will ask how long will they have to be in treatment. My response is simply - "As long as you want to be." To ask how much treatment is needed is like asking how much education one needs. Some people-3 are satisfied with a bachelor's degree-, some want half a dozen Ph.D.'s and a Cosmetology License. This is not a model where people are sick and ask the doctor to fix them. This is a place where one overcomes problems by growing as a human being not by stifling one's humanity. When you are satisfied with your work here then I assume you will leave.

I am also frequently asked questions that raise spurious issues such as but what would you do if..." then some extreme stereotypical behavior or perceived threat or dangerousness is postulated in order to justify dehumanizing interventions. Often these behaviors can be traced to the reaction human beings have to being betrayed by those who purport to help them - if only they will surrender their humanity to serve as scapegoats for the collective pervasive, if unspoken, belief of our profession that those identified as "mentally ill" have something wrong or inferior about them that we are safe from as long as we can identify its existence in someone else. Or as Thomas Szasz once put the problem (comparing it to the biological principle of "kill or be killed") in the mental health community it is "label or be labeled."

Often, much of what we do in the first stages of treatment for people who have been in the psychiatric system for prolonged periods is to in essence " them to stop acting like "mental patients." Even those who have never been formally treated in the prevailing mental health system; even some who are well aware of the inhumanity of this system need both intellectual and emotional clarification of the distinctions between what is fact, fiction, politics and propaganda. In fact, it is true that even patients who come to us well informed, angry, and opposed to biopsychiatry's way of thinking still require some degree of attention to the subtle and often superstitious pressures of this oppressive model. Indeed, often find myself intimidated by the propaganda both for imagined and actual reasons.

 

TEN PRINCIPLES TO CREATE AN EMPATHIC MILIEU

This list of principles is neither exhaustive nor exclusive. Some of the ideas obviously overlap as they should in an integrated system. The list is articulated to specifically aid in the creation of an integrated treatment program. While these principles are meant to be applied to designing a treatment system it will be easy to see how they may be applied as well to the internal "milieu" of the therapist. Because of limited space there is little elaboration within the list but the underlying rationale for each is easily gleaned from this chapter in its entirety.

(1)Personal responsibility for life, well being, and behavior belongs unequivocally to the patient

(2)The physical environment of the facility must reflects these principles. (it would be impossible to expect someone to speak freely, no matter how sincerely encouraged, in a room displaying a Nazi party swastika.

(3) Philosophy is more important than technique.

(4) The most important job of the therapist is to create an empathic, healing environment.

(5)The therapist must eschew the arrogance that she or he "fixes" the patient and recognize that the capacity for healing is inherent in the psychological and spiritual makeup of the patient.

(6)Symptoms of psychological distress must be regarded as meaningful expressions rather than as parasites to be eliminated.

(7)The therapists passion for the work and meaning of psychotherapy must dominate the fears and insecurities of the work.

(8)It must be recognized that the primary means of healing employed by the human psyche is through expression in the context of an empathic relationship or community.

(9)The milieu must stress security not safety; constancy not immediate gratification and the development of personal autonomy not infantile dependency.

(10)Human suffering must be regarded as both inevitable and purposeful. The avoidance of suffering is one of if not the primary causes of psychological or spiritual crisis. The problem is how to make suffering a constructive experience that increases empathy and enriches our humanity rather than a destructive force that drives us away from our humanity.

 

A Day In the Life of SJPC

The activities of each day at SJPC are organized around five different group hours. Patients also meet with their individual therapist one or several times per week. Each group in the day program has its unique purpose and role. Overall the structure of the day is designed to wax and then wane in regard to depth and formality of structure while providing a variety of means by which the patients' psyches can express their needs.

The program is generally designed to approximate a work environment. There are no degrading level systems. Patients are not "sorted" out according to diagnosis.

We all suffer from fears, confusions and griefs. Some of us are more overwhelmed than others by our struggles with these experiences and manifest meaningful expressions of these struggles that are called "symptoms" but we are all trying to cope with the same basic elements of being human beings. Recognition of what we share as human beings brings us together in our humanity. Emphasizing our distinctions in labeling separates us.

Attendance is not mandatory. There are few official policies or posted rules. Instead there is an unwavering expectation of respectful behavior. There is a job to do. Each person involved in the program whether staff or patient plays a part in the work. The work is dedicated to the growth of each human being participating in the program both individually and collectively. The "work" is to help human beings grow. It is not to identify symptoms to be eliminated.

Beginning at nine in the morning the patients gather with staff members for a community meeting. This meeting serves as something of a "warm up." A member of the patient community is selected by his or her peers to conduct this meeting. It is intended to function as something of a business meeting and has an informal agenda. Everyone is greeted and given an opportunity to comment on how they are feeling that day. News and announcements are made. Community Issues are discussed and individual and group goals are set. However, all the tasks of this agenda are secondary to and in fact in service to the needs of the participants.

After a short break the group reconvenes at 10:00 for an expressive arts group. In this group members have an opportunity to express their humanity through Various media that are less dependent upon the cognitive/ verbal skills that we have best developed yet can often be co-opted by our fears to avoid intimacy and growth.

At 1 1:00 a traditional group therapy session is scheduled. This is the heart of the Integrated Milieu. Patients explore their fears, their wishes, their wounds.

At noon there is a lunch break In keeping with the notion of approximating a work environment there is no specified nor mandatory means by which any patient or staff member pass the lunch hour. Some bring a sack lunch. Some will cook something alone or for the group. Some will run errands or go out to lunch. Some will take a nap etc.

At one o'clock another group begins. This time it is a discussion group. A topic is chosen by the group. Ideas are shared. Thoughts discussed. The world figured out-at least till tomorrow.

At two the day ends with a recreation hour. The purpose and necessity of play is often under appreciated in our culture. It is a time to bond, to relax, to re-create. At the end of the recreation group the program day ends. Patients are then on their own until nine the next morning.

The structure of the milieu program is designed to maximize the ability for the therapists to facilitate the healing. Structure, regularity, and constancy tempered by flexibility, empathy and nurturance are essential to a healing environment. But there is no magic formula. As emphasized previously it is the philosophy of the integrated milieu that determines the form. Not the other way around. The exact same form as used at SJPC may be duplicated by any facility. Indeed the program model is a classic template used in many psychiatric facilities. But without absolute commitment to the humanity of the individual it is a lifeless, soulless shell.

The use of a strictly day treatment milieu is also deliberate. While it is important to provide an environment or program of intensive and multidimensional therapeutic activities there must be a beginning and an end. An over structured 24 hour environment can easily infantile patients. Ending the "work" day preserves the patients ability to comfort, care for, and entertain themselves increasing not only their basic sense of autonomy but also reinforcing the confidence and trust that they can in fact, "make it through the night' and do not need to structure their lives and the lives of everyone in their environment to be geared to the demands of immediate gratification. It is much more psychologically secure to know that there is a tomorrow than to try to create and sustain an illusion that we will never have to feel alone or afraid.

Finally, the therapeutic milieu must be a stable beacon, not a search and rescue operation. Certainly, there are times when people need immediate and direct intervention in their lives. This is important to our lives as a community. But this is not psychotherapy. Psychotherapy's power is dependent upon constancy and reasonableness. Psychotherapy has no potency in areas where panic and hysteria reign. That is the domain of pathology and dysfunction. A milieu geared to react to panic will soon be in service of it. In other words, if someone is given the mixed' message that she or he is responsible for his or her own life and well being unless they present with a crisis at which time the constancy of the milieu will be discarded. People who dread taking responsibility for themselves (as we all do) will be behaviorally trained by the milieu to be in crisis. In this way they can avoid the terror of personal responsibility or gain control over the situation or to simply to gain immediate but ultimately, ungratifing attention.

What About Drugs?

Although many people seek out SJPC because of our unique service of helping people discontinue psychiatric drugs it is not the primary mission of the clinic. The primary mission is to provide in depth psychotherapy uncompromised by dehumanizing attitudes, technologies or techniques. Psychiatric drugging is simply one of the more obvious and currently the most pervasive means of dehumanizing patients.

Patients wishing to decrease or eliminate their use of psychotropic drugs follow a customized titration protocol that addresses both the physical and psychological issues of withdrawal from these drugs. However, it is strongly emphasized that neither the method nor the goal is focused on merely discontinuing psychotropic drugs. The purpose of the program is to substitute immersion in a high quality, intense, in-depth sophisticated and empathetically based treatment program for drugs and other technologies in order to enrich the person's humanity and thus alter their struggles with suffering from a destructive dehumanizing form to a constructive uplifting form.

An Integrative Conclusion

I held my first job in this field at age sixteen. I was a "Play Therapy Aide" at Boston's Children's Hospital. I worked on a ward that was designated for children who were terminal. In a paper written years later as an undergraduate for a Medical Sociology course I noted that I found myself most impressed that the children there, although undeniably dying, were most busy being children. They were living.

At that time there were also many children who suffered from various cancers. Many had limbs removed to stop the disease. It was the best they could do at the time. But no one in the field ever said that it was good enough treatment to rid the cancer from these unfortunate children by compromising their wholeness. The entire field of medicine has always advanced when it has concentrated not so much on stopping 'the disease as preserving and advancing the integrity of the person. This must be our goal for those who suffer psychological distress as well. The necessary evil argument that controlling symptoms at the expense of human dignity and integrity can not be good enough.

Human beings are designed to heal from their suffering; even to grow from it. But the source of healing is not found in drugs and electric shock or surgery or the other trappings of biopsychiatry. These things dehumanize us. Instead of techniques and technologies that further impair our humanity the sources of healing must be sought in the things that make us human. These things include literature, art, music, laughter, play, community and of course, basic human empathy. We must seek always to struggle productively with our suffering; expanding, deepening, expressing and sharing our humanity.

As John Steinbeck proclaimed in his introduction to "East of Eden", his quintessential novel of human nature: "And this I believe: that the free exploring mind of the individual human is the most valuable thing in the world. And this I would fight for: the freedom of the mind to take any direction it wishes, undirected. And this I must fight against: any idea, religion or government which limits or destroys the individual. This is what I am and what I am about. I can understand why a system built on a pattern must try to destroy the free mind, for that is the one thing which can by inspection destroy such a system. Surely I can understand this , and I hate it and I will fight against it to preserve the only thing that separates us from the uncreative beasts."

"if the glory can be killed, we are lost!".