AWARENESS of the importance of milieu in psychiatry grew out of the work of the Tukes and of Dorothea Dix. Modern concepts of milieu therapy, the use of the total ward (institution) in a planned and calculated way for its therapeutic effect, is, however, largely an outgrowth of the work in psychiatry following World War II. Most of the literature is the report of impressions of programs in various settings (eg, shortterm wards, military psychiatric wards) or are descriptive of staff participation.

The models for milieu therapy vary widely, but all of them include overt participation of the patients in decision making. They also tend to stress and utilize the collective strength of the patient population. Psychiatric staff working in a milieu setting is confronted recurrently by the emergence of patient leaders who are antitherapeutic, negativistic, or destructive. Modification of these leaders' behavior and impact on the patient group, and,