Creating an Empathic
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
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
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
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
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
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
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
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
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
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
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
(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
(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
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
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
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,
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,
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
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
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 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!".