Abstract
Children, highly resistant to treatment as outpatients, can be treated in child psychiatric inpatient units where a therapeutic environment or `Therapeutic Milieu' is maintained. Using the theoretical framework described by Gunderson in 1978 (Psychiatry, 41, 327-335) case vignettes and an extended case study are used to illustrate how milieu therapy works within the context of a multidisciplinary team. Some points of difficulty in application are discussed. The key elements of milieu therapy are discussed: maintenance of a safe and containing environment, a highly structured programme, physical and emotional support, collective involvement of the child, family and staff in the unit regimen and continuous evaluation of all therapeutic interventions. Milieu therapy is contrasted with previous attempts to treat the children as outpatients. Although we now live in an era dominated by community-based treatment, the intractability of some chronic mental illness and its high cost to children and their families makes continued research and development in this area essential.
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