Milieu Therapy for Schizophrenia Invites Participation and Improves Treatment Outcomes

What should the relationship be between a clinician and a client? This question has guided a reframing of tradition clinician-client dynamics over the past decade, spurring us to move away from understandings of medical treatment as something that is done to the client toward an understanding of treatment as something the client is actively engaged in.

This new framing of what clinician-client relationships should look like has led to the development of milieu therapy for schizophrenia or the shared decision-making model, “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preference.”

This model represents a sharp deviation from what has become the standard dynamics in treatment for schizophrenia, which has historically been based on the idea that the nature of the illness itself prevents (or should prevent) participation in treatment decisions; people have not been trusted to participate. But in recent years, evidence has emerged suggesting that not only do people with schizophrenia want to participate in treatment decisions, but they can indeed participate successfully.

A group of European researchers released a new study on the impact of the shared decision-making model on various treatment markers. Called the DECIDE study, the researchers examined the impact of shared decision-making vs. traditional treatment on hospitalized clients with schizophrenia. The findings indicate “involving hospitalized schizophrenia patients in treatment decisions improves satisfaction and confidence in treatment” at discharge as well as at a 12-month follow-up.

The shared decision-making model was associated with greater non-pharmacological treatment adherence, a significant decrease in patient loss at follow-up, a reduction in days of hospitalization, and “a marked decrease in the number of patients taking more than two antipsychotic drugs. The average number of drugs taken per patient fell from four at baseline to two at the 12-month follow-up.” Moreover, “patients were subjectively more happy or satisfied with their medications.”

The study fortifies claims that shared decision-making can have a positive impact on people living with schizophrenia and is a viable participatory model of treatment. But what the study didn’t do was show that it also leads to better treatment outcomes overall. As Dr. Ofer Agid, a clinical scientist and psychiatrist at the Schizophrenia Program at the Center for Addiction and Mental Health in Toronto, says,

One of the major problems in schizophrenia is adherence with the antipsychotic treatment and this hypothetically—at least on face value—should impact dramatically the level of adherence. So here is a question: why didn’t we see the results?

Although more research must be done in order to investigate this question, it is possible that outcomes did not change significantly because psychopharmacology remained the primary mode of treatment and care was thus insufficient.

Schizophrenia deeply impacts each person afflicted with it in unique ways. However, the neurochemistry aspects of the illness are only one part of the puzzle. Schizophrenia may strip one of a sense of reality, but it also transforms what reality itself looks like. For many, schizophrenia profoundly affects how a person feels about themselves, how they relate to other people, and how they are in the world.

Thus, simply changing neurochemistry through psychopharmacology fails to address the full scope of suffering and functional deterioration associated with schizophrenia. Promoting pharmacological adherence alone is typically not enough to result in true recovery and modes of intervention that go beyond participation in medication decisions is necessary for successful treatment for schizophrenia.

Although participatory therapies are a hot topic these days, the idea of people being participants in rather than recipients of medical care has existed in some form for thousands of years. Perhaps the most powerful articulation of this in the world of mental health is milieu therapy, the roots of which date back to classical Greece.

Milieu therapy for schizophrenia is based on the principles that everyday living can be a therapeutic experience, therapeutic experience goes beyond treating acute symptomatology, and treatment itself must go beyond medication. Rather than focusing solely on psychopharmacology, milieu therapy provides ways of healing the whole person, fostering concrete living skills that translate into increased autonomy and self-determination, gradually decreasing reliance on mental health professionals. As such, it is ideal for people struggling with mental illnesses that have been stripped of the ability to live independently.

Milieu therapy in the context of long-term residential treatment programs is fundamentally based on client participation in treatment. The therapeutic community becomes an inherently participatory space in which clients are able to constantly make decisions regarding their own therapeutic experiences.

By living, interacting, eating, bonding, and processing in a therapeutic community setting, clients are able to learn invaluable, concrete emotional and behavioral skills that nourish independence in ways medication alone cannot. These include the ability to:

• Manage personal self-care
• Form meaningful relationships
• Engage in in-the-moment emotional regulation
• Resolve conflict
• Manage one’s own treatment

The long-term format of such programs allows clients to continuously practice new ways of showing up in the world until they come to naturally replace destructive alternatives, promoting true, lasting change.