Effectiveness of Milieu Therapy To Patients As Perceived by The Nursing Students Assigned at The Cavite Center For Mental Health

EFFECTIVENESS OF MILIEU THERAPY TO PATIENTS AS PERCEIVED
BY THE NURSING STUDENTS ASSIGNED AT THE

CAVITE CENTER FOR MENTAL HEALTH
An Undergraduate Research Proposal

Presented to
the Faculty of the School of Nursing
Emilio Aguinaldo College
Dasmarias, Cavite
In Partial Fulfillment
of the Requirements for the Degree
Bachelor of Science in Nursing
Carlos, Sheena V.
Cayas, Bernadette A.
Gellecanao, Bethoveen Jane C.
Manabat, Sarah Ciel A.
Pedillaga, Jossa Roma V.
January 2010
THESIS ABSTRACT
THESIS TITLE:
EFFECTIVENESS OF MILIEU THERAPY TO PATIENTS AS

PERCEIVED BY TRHE NURSING STUDENTS ASSIGNED
AT THE CAVITE CENTER FOR MENTAL HEALTH
Authors:
Sheena V. Carlos
Bernadette A. Cayas
Bethoveen Jane C. Gellecanao
Sarah Ciel E. Manabat
Jossa Roma V. Pedillaga
Adviser:
Maria Lailani D. Llamas RM, RN
This study aimed to determine the effectiveness of milieu therapy to

mental patients as perceived by the nursing students assigned at the Cavite
Center for Mental Health (CCMH).
Specifically, the study sought to answer the following questions:
1. What are the demographic profile of the nursing students as to:
1.1 Age
1.2 Gender
1.3 Birth order
1.4 Type of therapy practiced
2. What are the perceived effects of milieu therapy to mental patients?

3. Is there a significant relationship between the demographic profile of the
nursing students and their perception on the effectiveness of milieu
therapy to mental patients?
Hypothesis
There is no significant relationship between the demographic profile of the
nursing students and their perception on the effectiveness of milieu therapy to
mental patients at the Cavite Center for Mental Health.
Research Design
This research study utilized the descriptive research design. This method
provided both the qualitative and quantitative description of the general
characteristics of the group under study. It is also the most appropriate method
to use to obtain adequate and accurate interpretation of the data gathered for
this research.
Summary of Findings
The findings of the study were the following: that 64 nursing students
(92.75%) have ages ranging from 17-21 years; 75.36% of the respondents are
female.; 40 or 57.97% of the respondents are either 1 st or 2nd in birth order and
that 92.75% of the respondents practiced all types of milieu therapy to patients.
Majority or 43 nursing students (62.32%) perceived milieu therapy as a

moderately effective type of treatment to patients at the Cavite Center for
Mental Health.
At five percent (5%) level of significance with 4 degrees of freedom, the
computed chi-square value of 7.1744 was remarkably lower than the critical
value of 9.488. The null hypothesis is accepted. Therefore, there is no significant
relationship between age and the nursing students perception on the
effectiveness of milieu therapy to patients.
computed chi-square value of 2.7096 was lesser than the critical value of 5.991.
The null hypothesis is accepted. Therefore there is no significant relationship
between gender and the nursing students perception on the effectiveness of
milieu therapy to patients.
computed chi-square value of 6.6686 was lesser than the critical value of 9.488.
The null hypothesis is accepted. Hence, there is no significant relationship
between birth order and the nursing students perception on the effectiveness of
milieu therapy to patients.
computed chi-square value of 3.8612 was significantly lower than the critical
value of 12.592. The null hypothesis is accepted. Therefore, there is no
significant relationship between types of therapy practiced and the nursing
students perception on the effectiveness of milieu therapy to patients.
Conclusions
Based on the findings of the study, the researchers arrived at the following
conclusions:
1. The nursing student-respondents were mostly 17 to 21 years old; the
number of female being a lot greater than male respondents; usually
1st or 2nd in sibling position and were able to practice all types of milieu
therapy to patients at the Cavite Center for Mental Health.
2. Majority of the respondents perceived milieu therapy as a moderately
effective type of treatment to patients at the Cavite Center for Mental
Health.
3. There is no significant relationship between the demographic profile of
the nursing students and their perceptions on the effectiveness of
milieu therapy to patients at the Cavite Center for Mental Health.
Recommendations
In lieu of the abovementioned conclusions, the following recommendations
are proposed:
1. School of Nursing and Midwifery. The clinical instructors and faculty
members of the School of Nursing and Midwifery should consider the
findings of this study to enhance the their supervisory skills and
improved their method of instructions so that they would be able to
educate and guide the students along the different aspects of the
nursing profession; enabling them to become well trained, competent,
skillful and competitive nurses in the future.
Efforts should also be made by the School of Nursing and

Midwifery to enhance the Nursing curriculum directed towards enabling
the students to undertake hospital duties at various mental facilities to
expose and train them on the different methods of treatment for mental
patients and conduct more responsibilities as nursing apprentices to
build up their care-giving attitudes to improve their nursing skills and
competencies and develop their
social and behavioral attitudes
towards peers and patients alike

2. Student Nurse. The student nurse involved in the study should take
some initiative to learn the skills, theories and skills involved in the
conduct of a particular learning program so that he/she can put her
knowledge into practice. Thereby becoming a capable representative
of her field to help and assist in medical and nursing services in the
community.
3. Students and Researchers. Future researches should be explored
through replication or expansion of this study allowing for a better
representation of demographics to include such characteristics as the
students Grade Point Average (GPA) and exposure to other
treatments for mental patients. Likewise, future studies utilizing
students from other colleges and universities offering the same
program should be considered.
Chapter One
THE PROBLEM AND ITS SETTING
Introduction
In the past, the subject of mental illness was surrounded with mystery and
fear. Today however, the mental health sector have made tremendous progress
in understanding and, especially, in the ability to offer effective treatments. These
improvements and advancements helped in erasing the stigma tied to mental
illnesses. On the forefront of these treatments is milieu therapy.
Milieu is a French term for middle place or a middle ground; still, others
describe it as a life space (Notes, 2009). As defined by Wikipedia (2009), milieu
therapy is a planned treatment environment in which every day events and
interactions are therapeutically designed for the purpose of enhancing social
skills and building confidence. The milieu provides a safe environment that is
rich with social opportunities and immediate feedback from caring staff. The
milieu is not static but it is flexible and features normalizing and developmental
perspectives that use common structures familiar to all people, such as daily
routines, consistent rules and activities.
Milieu therapy is a form of psychotherapy. It is used by psychologists and
other health professionals who believe support and encouragement are the key
aspects of therapeutic success. (virtualmedicalcentre.com/medical_dictionary,
2009). It is designed to provide a secure retreat for persons whose capacities for
coping with reality have deteriorated and offers opportunities to acquire adaptive
coping skills while letting the patient test these new coping skills in a secure,
comfortable physical facility. Milieu provides recreational, occupational, social,
psychiatric, medical and nursing therapies. Likewise, it protects and shelters the
patient from perceived pain, terrifying stressors, or from their own or others
maladaptive behavior (Notes, 2009).
Ford-Martin (2009) asserted that the growing popularity of milieu therapies
at psychiatric institutions in the twentieth century was an important factor in the
development of recreational and art therapy. Activities that encourage selfdiscovery and empowerment such as art, music, dance, writing and play are
important components of this approach.
This research was meant to ascertain the effectiveness of milieu therapy,
specifically art, singing, dancing, play/games and food preparation/cooking
therapy, to mental patients at the Cavite Center for Mental Health located at
Trece Martires City in the province of Cavite, as perceived by the nursing
students assigned at the facility.
Background of the Study

The Cavite Center for Mental Health is an extension of the National Center
for Mental Health. The hospital was established as an independent entity under
Resolution No. 225-S-2000 by the Sangguniang Panlalawigan and approved by
the governor on May 08, 2000.
Pursuant to the Ministry Order No. 96 series of 1978, the Psychiatric Unit
was added to the original ward and administration building. It has expanded
since then, with services covering eleven (11) provinces and eight (8) cities of
Region IV. Its programs include occupational, recreational, rehabilitative, spiritual
and curative treatments.
For the past years, the hospital has been accommodating nursing
students from colleges and universities nationwide who are required by the
schools to allocate part of the academic period to conduct community service as
part of the curriculums training programs.
Seventy - one (71) fourth year nursing students from this College, under
the guidance of Clinical Instructors and supervision of the hospital staff, have
been conducting milieu activities with the patients of the mental facility. All have
been practicing art, singing, dancing, play/games and food preparation/cooking
therapies.
On this background, the researchers deemed it significant to ascertain the
perception of the students currently rendering training at the facility about the
effectiveness of milieu therapy on mental patients.
THEORETICAL FRAMEWORK
The concept of self-efficacy was used as the framework for this study. To
briefly explain, self-efficacy is a Theory of Motivation. It holds that one's
motivation to enact a behavior is tied to the expectancy that the behavior will
produce a particular outcome.
Moreover, if one desires the outcome and believes he or she is capable of
the behavior to produce it, then the individual will be more likely to persist at the
behavior. Two important aspects of self-efficacy are that it is generally thought of
as task specific and that it can be modified. Self-efficacy related to a task can be
increased by success at performing the skill as well as seeing others role model
success at the task. Self-efficacy can also be boosted when staff provides verbal
feedback to the person that he or she does possess the ability to perform a
specific skill (Bandura, 1989).
Using the theory as a basis for this study, it assumed that the nursing
student-respondents perception on the effectiveness of milieu therapy to mental
patients at the Cavite center for mental health is affected by their personal
characteristics, them being a part of the milieu group. The personal
characteristics include the nursing student- respondents age, gender and birth
order.
Thus, the respondents perception on the effectiveness of milieu therapy to
mental patients is influenced by age and birth order in the sense that it is often
assumed that older people and those who are first born are more likely to be
more compassionate, understanding, open to weighing possibilities and
potentials and nor act rashly because, more often than not, they are motivated to
do so by the expectations of their parents and the fact that they tend to set an
example to younger siblings among others; and, therefore, is more likely to view
the effectiveness of the therapy on a positive light.
Meanwhile, those who are younger in age and youngest in birth order are
thought of to be a bit subjective in their opinions or perceptions of a particular
condition or situation. Middle children, on the other hand, are generally thought of
as having their own mindset, either leaning on the emotional or the practical side,
their opinion is the product of years of growing up trying to be at par, if not
surpass, the achievements of the older sibling and at the same time craving the
attention given to the younger ones.
On the other hand, in terms of gender, female are thought more likely to
be swayed by emotions than their male counterparts, thus, male respondents are
expected to be more objective and the female, more subjective, in their
perceptions of the matter at hand.
Research Paradigm
Independent Variables
DEMOGRAPHIC PROFILE
OF NURSING STUDENTS
Dependent Variables
PERCEPTION OF NURSING
STUDENTS ON THE
EFECTIVENESS OF
1.1. Age
1.2. Gender
1.3. Birth order
1.4. Type of therapy practiced
Figure1. The Variables and their Relationship
Statement of the Problem
MILIEU THERAPY
1. Emotional
2. Social
3. Behavioral
In this study, the effectiveness of milieu therapy to mental patients as

perceived by the nursing students assigned at the Cavite Center for Mental
Health (CCMH) was ascertained.
Specifically, this study answered the following questions:
1.1 Age
1.2 Gender
1.3 birth order
1.4 types of therapy practiced
Hypothesis
There is no significant relationship between the demographic profile of the
nursing students and their perception on the effectiveness of milieu therapy to
mental patients at the Cavite Center for Mental Health.
Scope and Delimitation

The study focused on the perceptions of the nursing students assigned at
the Cavite Center for Mental Health on the effectiveness of milieu therapy to
patients, specifically art, singing, dancing, play/games and food preparation and
cooking therapies.
It covered a total of 69 nursing student-respondents from Emilio Aguinaldo

College in Dasmarias, Cavite who rendered hospital duty/training at the Cavite
Center for Mental Health located at Trece Martires City in the province of Cavite.
Significance of the study

This
research
provides
the
nursing
student-respondents,
health
workers/personnel and professionals, government officials, the College, and

researchers relevant information regarding the effectiveness of milieu therapy to
mental patients.
Nursing student-respondents
Findings of this study can help the nursing student-respondents by
providing an in-depth review about their perception of milieu therapy and the
important part they play on achieving positive outcomes from the therapy.
Findings will likewise provide additional mental health education as to
what interventions/approaches are necessary to attain what they hoped to
accomplish.
Mental health center administrators and staff
The administrators of the Cavite Center for Mental Health, other
mental health facilities, medical professionals such as doctors, psychologists,
psychotherapists, occupational therapists, nurses and social workers may use
the findings of this study in the providing appropriate interventions such as
conducting seminars and training programs for nursing students and other health
workers that may help facilitate a better understanding of the concept of milieu
therapy thereby making these health professionals /workers more equipped to
practice it. The findings of this study may also be used by the hospital
administrators in the formulation of mental health policies that will lead to the
enhancement of the milieu therapy programs that will be beneficial to the
patients.
Government officials and non-government organizations
The Department of Health in coordination with the National Center
for Mental Health and local government units may use the findings of this study
to plan and develop mental health policies and programs that would lead to
enactment of specific mental health laws to improve the condition of the patients.
The College
The college administrators and faculty may use the findings of this
study in creating additional subjects and/or school programs that will focus on
mental health approaches that the students can apply during the conduct of
community outreach programs.
Nursing students and future researchers
Finally, findings of this study may be used as reference material by
students and researchers conducting similar or related studies.
Definition of Terms
The
following
terms
were
operationally
defined
for
the
better
understanding of the study:

Effectiveness
Refers to the efficiency or usefulness of using milieu

therapy to mental patients which may be classified as
either
highly
effective,
moderately
effective,
effective, not so effective or not effective.

Mental Patients
Refer to the patients presently undergoing milieu

treatment at the Cavite Center for Mental Health in
Trece Martires City, Cavite handled by the fourth year
nursing students from Emilio Aguinaldo College in
Dasmarias, Cavite.
Milieu Therapy
In this research, this will be limited to art, singing,

dancing, play/games and food preparation/cooking
therapies.
Nursing Students
Refer to fourth year nursing student-respondents from

Emilio Aguinaldo College in Dasmarias, Cavite
rendered hospital duty at the Cavite Center for Mental
Health in Trece Martires City, Cavite.
Perception
The
opinion
of
the
nursing
students
on
the
effectiveness milieu therapy to mental patients based

solely on their observations of the emotional, social
and behavioral responses/actions of the patients.
Chapter Two
REVIEW OF RELATED LITERATURE
This chapter presented a review and survey of related literature. To gather

materials in the preparation of this study, the researchers conducted systematic
studies of several books, foreign and local studies, journals, bulletins and other
reading materials related to the problem. These literatures provided the
researchers a much deeper and clearer understanding of the subject at hand.
Related Readings
The Philippine Nursing Act of 2002, Republic Act No. 9173, Article V,
known as the Nursing Education, Section 25 indicates that the nursing education
program shall provide sound, general and professional foundation for the practice
of nursing. The learning experiences shall adhere strictly to specific requirements
embodied in the prescribed curriculum as promulgated by the Commission on
Higher Educations policies and standards of nursing education.
On Article VI, section 25 of the same Act, it was further stated that a
person shall be deemed to be practicing nursing within the meaning of this Act
when she/he singly or in collaboration with another, initiates, performs nursing
services to individuals, families and communities in any health care setting
(Aquino et al., 2003).
Mental health law is the area of the law that is applied specifically to
persons with a diagnosis or possible diagnosis of mental illness, and to the
people involved in managing or treating others in this situation. This includes
areas in both common law and statute law. Common law, which is based on case
law rather than statutes,
issues include such concepts as mens rea,
insanity
defenses,
sane and insane automatism
amongst
others. Statute
law
usually takes the form of a Mental health act. or equivalent. An example is the
Mental Health Act 1983 in England and Wales. These acts codify aspects of the
treatment of mental illness and provide rules and procedures to be followed and
penalties for breaches. Mental health acts are largely used in the management
of psychosis where a person has lost the ability to test reality. They may also
be used for other conditions including personality disorders. The laws generally
allow
for compulsory treatment in a psychiatric hospital or in the community. In
some
jurisdictions court orders are required for compulsory treatment while in
others treating psychiatrists may treat compulsorily by following set procedures.

There is no mental health law in the Philippines. The laws that govern the
provision of mental health services are contained in various parts of the
Administrative and Penal Code promulgated in 1917. The prevention, treatment
and rehabilitation from substance abuse are covered in the Dangerous Drugs
Act, which was revised in 2001. A Dangerous Drugs Board is responsible for the
policy; a Presidential Drug Enforcement Agency implements the policy and the
Department of Health supervises and monitors the laboratories where drug
testing, treatment and rehabilitation take place.
In April 2001, the Secretary of Health signed the National Mental Health
Policy, which is now known as Administrative Order No. 8, Series 2001. Although
signed in April 2001, the policy has still to be presented and implemented by the
various stakeholders in mental health. The Philippine Mental Health Policy was
drafted in 2001 and signed by then Secretary of Health Manuel Dayrit. It has the
following policy statements: (1) leadership, (2) collaboration and partnership, (3)
empowerment and participation, (4) equity, (5) standards for quality mental health
services, (6) human resource development, (7) health service delivery system,
(8) mental health care, (9) stability and sustainability, (10) information system,
(11) legislation, and (12) monitoring and evaluation. The NMHP has identified six
areas of priority concerns, namely: mental disorders; substance abuse; disaster
and crisis management; women, children and other vulnerable groups; epilepsy;
and overseas Filipino workers. With the exception of epilepsy, the other five
areas of priority were already provided for in the previous National Mental Health
Program. In the treatment of mental disorders, the NMHP has articulated its
support for the policy shift from mental hospital-based psychiatric treatment to
community-based mental health care, a first step in the opening up of acute
psychiatric units and outpatient clinics in all 72 government hospitals and the
provision of psychiatric drugs (Conde, 2004).
The last revision of the mental health plans took place in 2005 to be
consistent with the National Objectives for Health (NOH) 2005-2010. The mental
health plans reaffirmed both the National Mental Health Policy and the NOH
2005-2010, which outlined the goals and objectives to be achieved by the health
sectors by 2010. It also specified strategies for national reform from an
institutionally based mental health system to one that is consumer focused with
emphasis
on
supporting
the
individual
in
the
community.
There
is
disaster/emergency preparedness plan for mental health. The present national
therapeutic drug policy/essential list of drugs in the country was formulated in

1988 (Reyes et al, 2007).
Furthermore, there is the National Center for Mental Health (NCMH)
dedicated to deliver preventive, curative and rehabilitative range of quality mental
health services. It is categorized as Special Research Training Center and
Hospital under Department of Health on January 30, 1987. NCMH was
established through Public Works Act 3258. It was formally opened on December
17, 1928 and was originally called the Insular Psychopathic Hospital. It was later
called the National Mental Hospital. On November 12, 1986, it was renamed
National Center for Mental Health through Memorandum Circular No. 48 issued
by the Office of the President (Conde, 2004).
The Cavite Center for Mental Health (CCMH), formerly an extension of the
NCMH, was established as an independent entity under Resolution No. 225 s.
2000 by the Sangguniang Panlalawigan as approved by the Provincial Governor
on May 08, 2000. The passage of Presidential Decree 1541 which provided for
the creation of the Regional Mental Health Center made CCMH the mental
hospital of Region IV (ccmh@yahoogroup.com, 2009).
Related Literatures
Milieu therapy has been in existence since the late 1800's when moral
treatment and therapeutic communities were key issues in the treatment of
psychiatric problems. It has been used as a viable treatment modality for kids for
over fifty years in residential and inpatient settings and more recently in the
partial hospitalization and day treatment settings. August Aichorn, Bruno
Bettelheim, Fritz Redl and David Wineman were among the early pioneers in
using milieu therapy to treat "impulse-ridden and ego-impaired" kids in residential
and school settings as early as the 1920's. Their work collectively has taught that
milieu therapy can be a powerful therapeutic tool when individual dynamics and
the social system can be combined in a planned and meaningful way to manage
and change behavior and relationships (http://en.wikipedia.org/wiki/, 2009)
The milieu, as described in the article, is not static but it is flexible and
features normalizing and developmental perspectives that use common
structures familiar to all people, such as daily routines, consistent rules and
activities. The milieu, or "life space" is planned in such a way that it is constantly
supporting, guiding and reinforcing a person's ability to learn life tools, such as
problem solving and coping skills, while at the same time offering a safe place for
these skills to be practiced and integrated into the person's repertoire of
strategies The milieu takes into consideration the perspective of the person as
well as the perspective of the milieu at large.
Notes (2009) averred that milieu refers to the people and all other social
and physical factors in the environment with which the patient interacts. This may
be 24 hours a day or partial. This environment is designed to provide a secure
retreat for persons whose capacities for coping with reality have deteriorated. It
offer opportunities to acquire adaptive coping skills and lets the patient test them
these new coping skills in a secure, comfortable physical facility. Milieu also
provides recreational, occupational, social, psychiatric, medical & nursing
therapies. It protects & shelters the patient from perceived pain, terrifying
stressors and can protect a person from their own or others maladaptive
behavior (i.e. attempt at suicide or abuse by spouse). This therapy supports the
patient physiologically, provides pleasant attractive sensory stimulation, teach
patients & family adaptive coping strategies.
The author further emphasized that the total milieu is a group therapy
approach to living experience with the following objectives: (1) correct or redefine
perception of stressors, (2) correct maladaptive behavior, (3) develop adaptive
coping, (4) acquire interpersonal & stress-management skills, and (5) apply all of
these in a social content . The article affirmed time and again that it is very
important that the milieu match the patients cultural background because its
absence to match can causes greater cognitive or inner conflict. In terms of the
overall goal of the mental health team, it aims to maintain and create a
therapeutic milieu by - providing individualized treatment plans, promoting selfgovernance, progressive levels of responsibility, and variety of activities, links
with family and community and effective interaction among health team who are
humanistic.
The nurses role and function in the therapeutic milieu includes (1)
managing and coordinating from a holistic view rather than a fragmented
perspective of other milieu therapy team members as this allows nursing to
ensure continuity of care, (2) assessing physiological and psychological status
continually, influence of the milieu therapy, (3) providing physical and safety care,
medication administration and education, psychosocial care, mental health and
health education. The nurse performs, when needed, brief on-the-spot reality
therapy and limit setting to help the patient deal with destructive behaviors.
Therapy by the nurse aims to increase self-awareness by helping the patient
clarify and correct perceptions of current stressors, identify their thoughts and
feelings toward the stressors and how they affect their behavior and test the
methods in the milieu (http://www.angelfire.com/ns/southeasternnurse, 2009).
One of the more popular method applied at milieu settings is art therapy or
art psychotherapy (http://psychology.wikia.com/wiki/, 2009). Art therapy is also
type of psychotherapy that uses art-making and creativity to increase emotional
well-being. The American Art Therapy Association disclosed that art therapy is
based on the belief that the creative process involved in making art is healing
and life-enhancing. Through creating and talking about art with an art therapist,
one can increase awareness of self, cope with symptoms, stress, and traumatic
experiences, increase cognitive abilities, and enjoy the life-affirming pleasures of
artistic creativity. Art therapists are professionals trained in both art and therapy
and hold a master's degree in art therapy or a related field. Art therapists work
with children, adolescents, and adults and provide services to individuals,
couples, families, groups, and communities. The term art therapy generally
applies to the use of the visual arts in psychotherapy, while creative arts therapy
refers to the use of art therapy, dance therapy, drama therapy, music therapy,
poetry therapy and psychodrama. Expressive arts therapy is a term that overlaps
with creative arts therapy, and generally refers to the use of performing arts for
psychotherapeutic purposes (Eyberg, 2008).
The American Music Therapy Association, Inc. reported that music therapy
is the clinical and evidence-based use of music interventions to accomplish
individualized goals within a therapeutic relationship by a credentialed
professional who has completed an approved music therapy program. Music
therapists assess emotional well-being, physical health, social functioning,
communication abilities, and cognitive skills through musical responses; design
music sessions for individuals and groups based on client needs using music
improvisation, receptive music listening, song writing, lyric discussion, music and
imagery, music performance, and learning through music; participate in
interdisciplinary treatment planning, ongoing evaluation, and follow up. Children,
adolescents, adults, and the elderly with mental health needs, developmental
and learning disabilities, Alzheimer's disease and other aging related conditions,
substance abuse problems, brain injuries, physical disabilities, and acute and
chronic pain, including mothers in labor. Music therapists work in psychiatric
hospitals, rehabilitative facilities, medical hospitals, outpatient clinics, day care
treatment
centers,
agencies
serving
developmentally
disabled
persons,
community mental health centers, drug and alcohol programs, senior centers,
nursing homes, hospice programs, correctional facilities, halfway houses,
schools, and private practice.
The idea of music as a healing influence which could affect health and
behavior is as least as old as the writings of Aristotle and Plato. The 20th century
discipline began after World War I and World War II when community musicians
of all types, both amateur and professional, went to Veterans hospitals around
the country to play for the thousands of veterans suffering both physical and
emotional trauma from the wars. The patients' notable physical and emotional
responses to music led the doctors and nurses to request the hiring of musicians
by the hospitals. It was soon evident that the hospital musicians needed some
prior training before entering the facility and so the demand grew for a college
curriculum. The first music therapy degree program in the world, founded at
Michigan State University in 1944, celebrated its 50th anniversary in 1994. The
American Music Therapy Association (AMTA) was founded in 1998 as a union of
the National Association for Music Therapy and the American Association for
Music therapy. MTA promotes a vast amount of research exploring the benefits of
music as therapy through publication of the Journal of Music Therapy, Music
Therapy Perspectives and other sources. Music is used in general hospitals to:
alleviate pain in conjunction with anesthesia or pain medication: elevate patients'
mood and counteract depression; promote movement for physical rehabilitation;
calm or sedate, often to induce sleep; counteract apprehension or fear; and
lessen muscle tension for the purpose of relaxation, including the autonomic
nervous system. Music therapy allows persons with mental health needs to:
explore personal feelings, make positive changes in mood and emotional states,
have a sense of control over life through successful experiences, practice
problem solving, and resolve conflicts leading to stronger family and peer
relationships.
Since music therapists serve a wide variety of persons with many
different types of needs there is no such thing as an overall typical session.
Sessions are designed and music selected based on the individual client's
treatment plan ( http://www.musictherapy.org/faqs.html, 2009).
Related Studies
Foreign
A pragmatic experiential testimonial by Bettleheim cited in a study
conducted by Zummo (2007) for the Institute for Clinical Social Work in Chicago,
Illinois entitled Measuring the Impact of Milieu Therapy for Students Excluded
from Public Schools stated in brief that for very disturbed persons, the impact of
classical psychoanalysis is not enough to promote the necessary personality
changes; the impact of psychoanalysis itself, or of a life organized on its basis,
had to be in effect all the time, not just for one hour of the day It had to be an
environment that offered meaningful human relations, satisfying living conditions
and significant goals, not simply an application of psychoanalysis to the life they
already knew. This is the first description of what will later be known as milieu
therapy. Bettelheims experience as a Jewish inmate in a Nazi concentration
camp during WWII prompted a profound awareness of the tremendous impact of
environment on behavior and personality. The impact of the concentration camp
undid within a few weeks what years of a useful and successful analysis had
done. He saw rapid changes taking place in his behavior and personality. Up to
this point, Bettelheim believed that the personality-shaping influence of the
immediate family was all-important and that society in the broader sense was
relatively negligible by comparison. He also believed that nothing compared to
psychoanalysis for freeing the individual and guiding him to higher integration.
The camp experience taught Bettelheim that the cohesive environment could turn
personality upside down in mature adults as well as in small children.
Psychoanalysis is not the most effective way to change personality. Being placed
in a particular type of environment can produce much more radical changes, and
in a much shorter time. Psychoanalytic theory was inadequate to explain fully
what happened to the prisoners. Applied within the appropriate frame of
reference it clarified much. Applied to phenomena outside of its province, it
distorted their meaning instead of clarifying them (Zummo, 2007)
Furthermore, it was revealed that little has been written on psychoanalytic
milieu therapy utilizing an out-patient school. The focus of most research has
been on residential settings. Residential programs provide twenty-four-hour-aday care with a wide range of activities and treatment interventions to assist
disturbed people in dealing with life experiences in a consistent and productive
manner. Establishing interpersonal relationships in the therapeutic environment is
seen as essential for effective positive growth and increasing self esteem for
successful treatment. His research was meant to quantify the value of milieu
therapy utilized at the Jeanine Schultz Memorial School, a private day program
designed to meet the needs of the students whose emotional, behavioral and
learning difficulties have lead to their dismissal from the public school system.
Since the youngsters have various backgrounds, personalities, and problems, a
therapeutic milieu in a residential treatment center is often characterized by
consistent rules and routines, program activities, group sessions, individual
psychotherapy, conflict interventions, family treatment, parent groups, and
special education. The author thus claimed that the classroom can become an
additional environment in which to evaluate and enhance a childs behavior as
the teachers participate in the students treatment. Recreational therapies like
visual arts, drama, dance and play were employed most of the time although
psychotropic drugs were also used.
A study on the benefits of expressive writing in lowering rumination and
depressive symptoms by Gortner, Rude and Pennebaker (2006) has found that
expressive writing can reduce depression symptoms among women who were
victims of domestic violence. It also helps college students at risk for depression.
Expressive or creative arts therapy is based on the idea that people can help
heal themselves through art, music, dance, writing, or other expressive acts.
In the 1950s two in-hospital approaches were developed, milieu therapy
and token economy programs. They often brought improvement and particularly
helped patients to care for themselves and feel better about themselves. Milieustyle programs have since been set up in institutions throughout the Western
world. The programs vary from setting to setting, but at a minimum staff members
try to encourage interactions (especially group interactions) between patients and
staff, to keep patients active, and to raise patients expectations of what they can
accomplish. Dobson et al, (2005) tracking the progress and status of mental
health care in the United States of America documented in a study entitled
Treatments for Schizophrenia and Other Severe Mental Disorders: Uncovering
the attitudes of community residents showed that, over the years, patients with
schizophrenia and other severe mental disorders in milieu hospital programs
often improve and that they leave the hospital at higher rates than patients in
programs offering primarily custodial care. Many of these persons remain
impaired, however, and must live in sheltered settings after their release. Despite
its limitations, the authors averred, milieu therapy continues to be practiced in
many institutions, often combined with other hospital approaches because it
produced positive outcomes. Moreover, they also stated that many halfway
houses and other community programs for individuals with severe mental
disorders are run in accordance with the same principles of resident selfgovernment and work schedules that have proved effective in hospital milieu
programs.
From a comprehensive bio-psycho-social point of view, a pilot-project
called Soteria (in Greek: delivery, salvation, protection), specially focused on
environmental and emotional factors, was therefore of particular interest. Loren
Mosher and Alma Menn conducted Soteria from 1971 through 1983 in a small
community-based experimental setting near San Francisco. There, young acute
schizophrenia patients were primarily treated by psychotherapeutic and milieutherapeutic methods. Soteria" stands for an alternative low-drug milieutherapeutic approach to acute schizophrenia that was first implemented by
Mosher and Menn in San Francisco, and since 1984 further developed by Ciompi
and co-workers in Berne, on the basis of their concept of affect-logic, that
emphasizes the often neglected influence of emotional factors in schizophrenia.
In both settings, equal and even partly better therapeutic results, compared with
traditional methods, were obtained with much lower doses of antipsychotics and
comparable daily costs. Basic concepts, practical proceedings and empirical

findings of Soteria Berne are reported, and their theoretical and practical
implications for mainstream psychiatry are discussed in an evaluative research
by Ciompi and Hoffmann (2004) entitled Conceptual Bases of Soteria Berne:
Therapeutic Consequences and Their Practical Realization in Soteria Berne
Clinical Observations. The results supported the hypothesis of a crucial
pathogenetic and therapeutic-preventive role played by emotional factors not
only in the so-called affective psychoses, but also in schizophrenia. As a
conclusion, Ciompi and Hoffmann affirmed that the Soteria experience supports
the assumption that emotional factors play a much greater role than generally
admitted in both normal and pathological modes of thinking and behaving,
including schizophrenic disorders. According to a somewhat provocative
statement formulated in summarizing a recent review of Soteria-like experiences,
"Soteria acts like a neuroleptic drug, but without its unfavorable side-effects".
Similar but probably more sustained (because more specifically problemcentered, context-related and personality-adapted) effects of basic emotional
states on thinking and behaving can be obtained in a natural way, as showed by
the Soteria experience.
Local
Reyes, et al (2007), in a report commissioned by the World Health
Organization to assess the mental health system in the Philippines using the
World Health Organization - Assessment Instrument for Mental Health Systems
(2007 WHOAIMS Report on Mental Health System in the Philippines: An
Assessment) revealed that the Philippines have a National Mental Health Policy,
Administrative Order # 8 s.2001, signed by then Secretary of Health Manuel M.
Dayrit. However, there is no mental health legislation and the laws that govern
the provision of mental health services are contained in various parts of
promulgated laws such as Penal Code, Magna Carta for Disabled Person, Family
Code, and the Dangerous Drug Act, etc. The country spends about 5% of the
total health budget on mental health and substantial portions of it are spent on
the operation and maintenance of mental hospitals. The new social insurance
scheme covers mental disorders but is limited to acute inpatient care.
Psychotropic medications are available in the mental health facilities. A
Commission on Human Right of the Philippines exists, however, human rights
were reviewed only in some facilities and only a small percentage of mental
health workers received training related to human rights. The National Program
Management Committee of the Department of Health (DOH) acts as the mental
health authority.
The report further disclosed that there was an effort by the National Mental
Health Program in the mid 1990s to integrate mental health services in
community settings through trainings of municipal health doctors and nurses on
the identification and management of specific psychiatric morbidities and
psychosocial problems. However, at present it appears that the majority of the
trained community-based health workers are no longer in their place of duty, and
the current primary health care staff seem to have inadequate training in mental
health and interaction with mental health facilities is uncommon.
The World Health Organizations Mental Health Atlas (2005), however,

cited that although the Philippines, like most countries of the Western Pacific
region, have a national mental health policy, in comparison to other countries, it
was put into operation relatively recently. Community care for patients is present,
but as seen in many low and lower middle income countries, it is limited. Unlike
the majority of countries in the world and the region, the Philippines have no
mental health law. The poor involvement of primary health care services in
mental health is also a feature shared with many low and lower middle resource
countries. The number of psychiatrists per 100,000 general population is similar
to the majority of countries in the Western Pacific region and about average for
lower middle resource countries in the world.
Still, the WHO Mental Health Atlas disclosed that the last revision of the
mental health plans took place in 2005 to be consistent with the National
Objectives for Health (NOH) 2005-2010. The mental health plans reaffirmed both
the National Mental Health Policy and the NOH 2005-2010, which outlined the
goals and objectives to be achieved by the health sectors by 2010. It also
specified strategies for national reform from an institutionally based mental health
system to one that is consumer focused with emphasis on supporting the
individual in the community. There is disaster/emergency preparedness plan for
mental health. The present national therapeutic drug policy/essential list of drugs
in the country was formulated in 1988.
Hamid, et al (2008), on the other hand, revealed that the Philippines has
a mental health policy that is hampered by a miniscule budget and limited
legislative authority.7,8 No mental health law has been established. Its mental
health budget is only 0.02% of its total health budget, the latter being 3% of its
GDP. The country lack data on refresher training for mental health staff, as well
as data on the number of organizations, associations or nongovernmental
organizations (NGOs) involved in mental health policies, legislation or advocacy.
And although the countrys Department of Health is beginning to make some
progress, albeit at a very slow pace. The crafting of the national mental health
policy is a potentially important first step, as is the national registration of persons
with disabilities.
A World Health Organization study of three developing countries, Iraq, the
Philippines and the former Yugoslav Republic of Macedonia, found that these
countries lack both epidemiological and area catchment studies of the mentally
ill. In the Philippines, in addition to funding difficulties, there are socio cultural
reasons why little attention has been paid to either the documentation of mental
illness or the evaluation of its treatment. Filipinos have traditionally viewed
mental illness as a form of evil possession, sorcery or punishment for
wrongdoing, and relatives with mental illness are often sent to traditional healers
or priests for exorcism. The Philippines Department of Health is beginning to
make some progress, albeit at a very slow pace. The crafting of the national
mental health policy is a potentially important first step, as is the national
registration of persons with disabilities. Established in the 1990s, its goal is to
identify individuals with disabilities, including those with mental illness, and to
develop rehabilitation programs and raise awareness (Hamada et al, 2008).
In relation to this, Reyes et al (2007) likewise revealed that 48 percent of

all admissions to community-based inpatient psychiatric units are involuntary.
The proportion of involuntary admissions to mental hospitals is 17%. The status
of voluntary/involuntary admission to other facilities is in general not taken into
account. However, it is estimated that the majority of admissions are involuntary.
The leading diagnoses of users treated in outpatient facilities are mainly
schizophrenia and related disorders and mood disorders. Information on
diagnosis is based on number of users treated. The average number of contacts
per user is 1.87. In terms of available treatments, a majority (51-80%) of the
patients received psychosocial treatments and most undergo milieu therapy. All
(100%) mental health outpatient facilities have at least one psychotropic
medicine of each therapeutic class (anti-psychotic, antidepressant, mood
stabilizer, anxiolytic, and antiepileptic medicines) available in the facility or a
near-by pharmacy all year round.
A World Health Organization (2007) country study reported that 4% of the
training for medical doctors is devoted to mental health, in comparison; training
for nurses is 5%. In terms of refresher training, 1% of primary health care doctors
have received at least two days of refresher training in mental health, while 2% of
the nurses have received such training. Thus, it is apparent that the nursing
profession plays an important role in pursuing an effective mental health program
in the country. Therefore, it is apparent that the elements necessary for pursuing
an effective mental health program in the Philippines are in place. The major
resource in the Philippines is its highly literate population who also values
education and professional development. Academic institutions and training

centers have in the last four decades developed good programs to educate and
develop
the
mental
health
human
resources, specifically psychiatrists,
psychologists, social workers, nurses and allied mental health professionals.

These have developed a multidisciplinary group of professionals to address the
mental health needs in the country, and have broadened the scope of the
national mental health program. In some ways these changes have advanced the
understanding of mental health disorders so that other agencies have initiated
mental health programs relevant to their special needs (WHO, 2007).
A case study presented entitled Case Studies of Drug Addicts Treated
with the Adopted Minnesota Model at Life Management Foundation (Abella,
2002) delved on the positive outcomes of adopting Minnesota Model which uses
milieu therapy to improve the quality of life of mentally unstable alcoholics and
chemical abusers. The Minnesota Model approach is typically characterized by a
thorough and ongoing assessment of all aspects of the clients and of multimodal
therapeutic approaches that includes group and individual therapy.
A more recent outcome study done by Randy Steinfield and Patricia
OBrien at Hazelden, the pioneer of the Minnesota Model focusing on alcohol and
drug abusers entitled Health Care Evaluation: Addictive Behaviors came up
with this results; that out of 1,083 male/female clients admitted and treated at
Hazelden at one year 53% remained totally abstinent and 35% had reduce
alcohol and drug use.
These results are similar to those reported by other
private institutions. A comparison to traditional psychiatric treatment approach
done in Helsinki, Finland, of 141 clients yielding, only 2% remained totally

abstinent in 70 80% response range showed in that one-year period
(www.mararahayka.org/, 2009).
Justification of the Study

Countries across the globe have long overlooked the issue of mental
health and mental illness. Countries spend little on mental health, especially
developing countries like the Philippines that allocate less than 1% of their gross
domestic product (GDP), while developed countries only spend about 5% of their
GDP. These figures are remarkable given that one single mental illness, unipolar
major depression, is today one of the top five leading causes of disability
worldwide and is expected to be the second leading cause of disability worldwide
by 2020 (Hamada et al, 2008).
A wide body of literature supports the use of milieu therapy in a mental
health capacity. And as the mind-body connection between psychological wellbeing and physical health is further documented by studies in the field, milieu
therapy gains greater acceptance as a therapeutic technique for mental illness
(Delaney, 2006). These improvements notwithstanding, the clinical field still has
far to go.
As such, this study may proved to be as exploratory and helpful as the
descriptive study conducted by Borgea and Fagermoenba in 2007 entitled
Wholeness and self-worth in time and space which focused on voluntarily
hospitalized patients experiences during planned admissions at a psychiatric
clinic. Their study described patients perceptions on what were essential
experiences for their recovery processes using qualitative interviews with 15

patients during their stay. Results of their study revealed that patients
experiences of wholeness and self-worth in time and space were found to be
decisive. Wholeness refers to a milieu setting describing the combination of
professionalism, kind hearts, and aesthetic qualities of the place. Altogether, the
study concluded that milieu therapy contributed to the patients experience of
self-worth and equality and that there is a need for further research to nd what
are the optimal therapeutic milieu and culture, and how these affect the recovery
processes.
With such minimal mental health funding, milieu therapy is one of the
treatments that may just meet the needs of the mental patients in our country
without causing undue pressure on the national budget.
There is a need
therefore to ascertain if milieu is indeed an effective treatment from the

perception of the nursing students assigned at a mental health facility in Cavite.
These students have been allowed to practice milieu therapy among the
patients and it would serve as an evaluation in itself; an assessment of their
ability to contribute to the health of the patients.
Furthermore, the study is distinct from others in the sense that this study
focused on the nursing students who were allowed to practice milieu therapy;
additionally, the effectiveness of such practice on mental patients was gauged
solely according to their perception. It is expected that their observation are not
as medically accurate, since the respondents do not have psychotherapy or
specialized training in the field of mental health, however, their perceptions may
bring an all-together new insight regarding milieu therapy from a care givers
point of view.
Chapter Three
METHODOLOGY
This chapter presents the materials and methods used in this study,
namely: research design, the population and sampling, the research instrument,
the validation and reliability of the instruments, the data gathering procedures
and statistical treatment of data.
Research Design
This research study utilized the descriptive research design. This method
provided both the qualitative and quantitative description of the general
characteristics of the group under study. It is also the most appropriate method
to use to obtain adequate and accurate interpretation of the data gathered for
this research.
Population and Sampling

Seventy-one (74) fourth year nursing students from six (6) sections of this
College rendered hospital duty/training at the Cavite Center for Mental Health
(CCMH). However, to avoid being misconstrued as causing undue influence to
the findings of the study, the researchers were not made respondents for this
study.
No sampling method was utilized for this study. A total of 69 fourth year
nursing students coming from the six (6) sections who rendered hospital
duty/training at CCMH were made respondents for this study.
Research Instrument
A survey questionnaire was prepared to gather information needed for this
study. The research instrument determined the demographic profile of the
respondents and their perception on the effectiveness of milieu therapy to mental
patients at CCMH.
Part I of the instrument consisted of questions about the demographic
profile of the respondents such as age, gender, birth order and the forms of
therapy practiced by the respondents at CCMH. Part II included questions on the
effectiveness of milieu therapy based on the observable emotional, social and
behavioral responses/actions of the mental patients.
Validity and Reliability of the Instrument

The validity and reliability of the instrument were verified after consultation
with experts in the fields of psychology and nursing. The suggestions of the
following experts, namely: Mr. Reynaldo J. Kilala, Ms. Giovannah H. Castillo and
Ms. Iverose T. Estorninos RN were included in the survey instrument.
Data Gathering Procedure

Permissions to conduct the research were obtained from the Dean of the
School of Nursing, the Hospital Chief of CCMH and the Chief Nurse of the same
facility.
The survey questionnaires were distributed to the respondents who have
rendered a total of at least 96 hours of hospital duty at CCMH. The
questionnaires were gathered and checked for completeness a week after

distribution.
Statistical Treatment of Data

Descriptive statistics such as frequency counts, mean, range, percentage
and rank were used to answer the first research questions. To answer the second
research question, respondents will be asked to describe their observations
using a 5-point Likert Scale (Streiner and Norman, 1992). The scale was
represented as:
5 always
4 often
3 sometimes
2 seldom
1 never
The resulting scores were interpreted as follows:
61 75
- highly effective
46 60
- moderately effective
31 45
- effective
16 30
- not so effective
0 15
- not effective
To answer the third research question, chi-square test was used. This
determined if there is a significant relationship between the demographic profile
of respondents and their perception on the effectiveness of milieu therapy to
mental patients. A five percent (5%) level of significance was used to determine
significant outcomes. The formulas for the statistical procedures are as follows:
1) Frequency:
f = N
where:
f - frequency
N
- total number of respondents
2) Percentage:
where:
_f _ X 100
N
- the size of the sample
N - the size of the population

3) Weighted mean:
WtdX = x
N
where:
WtdX - the weighted mean

N
total number of respondents
x - the sum
4) Chi-square test:
X2 =
(fo-fe)2
fe
where:
fo - observed frequency
fe - expected frequency
- summation
Chapter Four
PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA
This chapter deals with the presentation, analysis and interpretation of

data gathered from the survey conducted by the researchers on the effectiveness
of milieu therapy to patients as perceived by the nursing students assigned at the
Cavite Center for Mental Health. It presents the findings of the study in three
parts. Part I, the Demographic Profile of the Nursing Students shows the
frequency distribution of the respondents according to age, gender, birth order
and type of therapy practiced. Part II, the Perceived Effects of Milieu Therapy to
Mental Patients, is further categorized into; (5) Highly Effective, (4) Moderately
Effective, (3) Effective, (2) Not So Effective and (1) Ineffective. Part III, the
relationship between the demographic profile of the nursing students and their
perception on the effectiveness of milieu therapy to mental patients. The order of
presentation follows the sequence of the problem in Chapter One.
Part I
Demographic Profile of the Nursing Students
Tables 1, 2, 3 and 4 show the different items of information regarding the
Effectiveness of Milieu Therapy to Patients as Perceived by the Nursing Students
Assigned at the Cavite Center for Mental Health. Each table reveals the
frequency of the respondents in each category. It also indicates the percentage
distribution and presents the ranking to determine the item with the highest
surveyed respondents. Interpretation and findings for each profile are presented
at the end of each table.
Age
Table 1 presents the frequency distribution of the nursing students
according to age.
Table 1. The Frequency Distribution of the Nursing Students Assigned at
the Cavite Center for Mental Health according to Age
AGE
FREQUENCY
PERCENT
RANK
17 21
64
92.75%
22 - 26
4.35%
27 - 32
2.90%
Total
69
100%
As seen on Table 1, the age of the nursing student-respondents ranged

from 17 to 32 years. Majority of the respondents (92.75%) belonged to the
youngest age group with ages ranging from 17 to 21 years; three respondents
(4.35%) belonged to the 22 to 26 years old age bracket and another two
respondents (2.90%) belonged to the oldest age bracket of 27 to 32 years. This
shows that most of the respondents were able to pursue their career choice on
the regular academic schedule and only a few pursued nursing studies during
their late ages.
Gender
Table 2 shows the frequency distribution of the nursing students according
to gender.
the Cavite Center for Mental Health according to Gender
GENDER
FREQUENCY
(n = 69)
PERCENT
(%)
RANK
Male
Female
TOTAL
17
52
69
24.64%
75.36%
100%
2
1
The above table shows that of the 69 student nursing-respondents, 52 or

majority of the respondents (75.36%) are female and only 17 (24.64%) were
male. This indicated that a greater number of those who took up nursing are
women. This may be for the reason that, generally, nursing has always been
perceived as a female-dominated profession.
This finding agree with the results of a poll study conducted by Gallup
Consulting entitled Healing the Gender Divide revealed that in the tradition of
Florence Nightingale, the nursing role has been seen as one of caring, empathy,
and service-orientation -- qualities typically seen as more characteristic of
women. While this tradition encourages high levels commitment overall among
nurses, male nurses do not necessarily identify with it as strongly as their female
counterparts -- a potential barrier to attracting and retaining men to nursing.
Furthermore, results of the poll showed that despite shifting gender roles, patient
perceptions that men are doctors and women are nurses still hold true. The
Gallup Survey also found few teen-age boys interested in nursing careers (Rick
Blizzard, D.B.A., 2002).
Results of a related study published by the HSJ Health Science Journal
(Vol. 2, Issue 3, 2008) which aimed to determine what female and male
undergraduate nursing students think of males in nursing entitled Gender and
Career: Female and Male Nursing Students Perception of Male Nursing Role in
Turkey likewise agreed with the findings of this study; whereas, it was found out
that nursing continues to be seen as a fit position for females. Even male
students who study in nursing have role tension about nursing. Male students
desire to occupy mostly administrative positions in health care settings after their
graduation shows their intentions to distinguish themselves from female
colleagues (Akansel, N., Tunk, G. and Ozdemir, A. 2008).
Birth Order
Table 3 shows the frequency distribution of the respondents according to
birth order.
the Cavite Center for Mental Health according to Birth Order
BIRTH ORDER
FREQUENCY
(n = 69)
PERCENT
(%)
RANK
1st 2nd
3rd 4th
5th 7th
TOTAL
40
20
9
69
57.97%
28.99%
13.04%
100.00%
1
2
3
In terms of birth order in the family, Table 3 would show that the nursing
student-respondent is either the eldest or the youngest among his/her siblings.
More than half of the respondents (57.97%) are either 1 st or 2nd in birth order
obtaining rank number one, followed by 20 respondents (28.99%) who were
either the 3rd or 4th child. Third in rank were 9 nursing student-respondents
(13.04%) who were either the 5th, 6th or 7th child in the family.
Zupek (2009), in the article Career and Birth Order written for
CareerBuilder.com, revealed that a childs place in the family birth order may play
a role in the type of occupations that will interest him or her as an adult. First
born and only children may be more interested in cognitive pursuits than younger
siblings. Whereas later born children are more interested in artistic or outdoorrelated careers.
Similarly, Perry (2008) in his article entitled Birth order can determine
career choice published online by dvm360, a Veterinary Economics website,
stated that it appears that birth order can also factor into career choice.
Firstborns tend to pursue careers that require higher education, such as
medicine, engineering and law. Middle children often have excellent negotiating
and people skills, and they tend to seek work in nursing, law enforcement, and
firefighting. Last born gravitate toward artistic and outdoor jobs, as well as
careers in journalism, advertising, and sales.
These results coincide with the findings of this study which showed that
older and middle children in the family have a greater tendency to take up
medical-related fields as profession. This may be because they are likely to be
more caring, understanding and patient, among other virtues, since, being older
children, parents tend to rely on them for help on taking care of younger children
in the family. Thus, their care-giving attitudes are motivated and developed early
on.
Forms of Therapy Practiced
Table 4 shows the frequency distribution of the respondents according to
type of therapy practiced.
the Cavite Center for Mental Health according to Type of Therapy Practiced
PROFILE
FREQUENCY
(n = 69)
PERCENT
(%)
RANK
All
Art, music,
play/games
Play/games
Music, dancing,
play/games
TOTAL
64
92.75
1
3
1
2
1.45
2.90
2
69
2.90
100%
2
2
All but five of the 69 nursing students who were made respondents for this
study practiced all forms of milieu therapy to mental patients at the Cavite Center
for Mental Health. Sixty-four respondents (92.75%) applied art, music,
play/games, dancing and food preparation/cooking; 2 nursing students (2.90%)
practiced only play/games therapy and another 2 respondents (2.90%) practiced
music, dancing, play/games. Only one respondent (1.45%) practiced the
combination of art, music and play/games as forms of milieu therapy to mental

patients.
Findings would show that almost all of the nursing students assigned to
conduct their duties at the Cavite Center for Mental Health were able to learn and
practice all forms of milieu therapy employed by the mental facility. This shows
that the staff at the mental facility were able to teach each nursing on duty the
techniques on milieu therapy, and the respondents, in turn, were able to practice
the same to the patients.
Part II
Perceived Effects of Milieu Therapy to Mental Patients
The use of milieu therapy to mental patients confined at the Cavite Center
for Mental Health was observed to affect the emotional, social, behavioral
conditions of the mental patients.
The emotional manifestations exhibited by the mental patients include the
following: (1) sign of gaining hope and aspirations; (2) feeling of acceptance and
belongingness; (3) awareness that she/he is not alone; (4) decreased levels of
anxiety; and (5) seem to be able to resolve conflicts/problems on her/his own.
On the other hand, the social manifestations observed on mental patients
who had undergone milieu therapy include: (1) willingness to participate in milieu
therapy sessions; (2) development of important interpersonal skills; (3) ability to
express personal feelings openly and directly to others; (4) maintenance and
initiation of good grooming; and (5) showing signs of improvement on general

appearance.
The behaviors of the mental patients are also perceived to be affected by
milieu therapy. Mental patients who were subjected to milieu therapy (1) appear
to be free from delusions and hallucination; (2) interact with reality-based topics
and interactions; (3) observed to be free from any physical/bodily injury (selfinflicted); (4) cease to exhibit negative/aggressive behaviors; and (5) interact with
reality-based topics and interactions.
For the interpretation of the results, the following scores were used:
SCORE
61 - 75
46 - 60
31 - 45
16 - 30
0 - 15
INTERPRETATION
Highly Effective
Moderately Effective
Effective
Not So Effective
Not Effective
Table 5 shows the nursing students perception of the effectiveness of

milieu therapy to patients as perceived by the nursing students assigned at
CCMH.
Table 5. The Perception of the Nursing Students on the Effectiveness of

Milieu Therapy to Patients as the Cavite Center for Mental Health
SCORE
61 - 75
46 - 60
31 - 45
16 - 30
0 - 15
TOTAL
LEVEL OF
EFFECTIVE FREQUENCY
NESS
(n = 69)
Highly
effective
Moderately
effective
Effective
Not so
effective
Ineffective
RANK
PERCENT
(%)
11
15.94%
43
15
62.32%
21.74%
0
0
69
0.00%
0.00%
100%
3
1
2
-
Findings of the study as revealed in Table 5 show that that the perception
of the nursing students assigned at the Cavite Center for Mental Health on the
effectiveness of milieu therapy to mental patients ranged from being effective to
highly effective; the lowest overall score being 36 points and the highest overall
score being 72 points.
Of the 69 nursing student-respondents interviewed, 11 respondents
(15.94%) perceived milieu therapy as a highly effective form of treatment to
mental patients, with respondents observation obtaining scores ranging from 61
to 75; 43 respondents or majority of the nursing students (62.32%) perceived the
same as a moderately effective form of treatment, with scores ranging from 46
to 60; while the remaining 15 respondents (21.74%) perceived milieu therapy as
an effective treatment to mental patients giving scores ranging from 31 to 45.
None of the nursing students perceived milieu therapy as a not so effective or
ineffective form of treatment to patients at the Cavite Center for Mental Health.
Part III
Relationship Between Demographic Profile of the Nursing Students and
their Perception on the Effectiveness of Milieu Therapy to Mental Patients
This section discusses the relationship of demographic profile such as
age, gender, birth order and types of therapy practiced by the nursing students to
patients at the Cavite Center for Mental Health to their perceptions on the
effectiveness of milieu therapy.
To answer the question as to the relationship of
the nursing students profile to their perception on the effectiveness of milieu

therapy to patients, a test of association, chi-square test, was used.
Age and Perceptions on the Effectiveness of Milieu Therapy
Table 6 shows the relationship between the perceptions on the
effectiveness of milieu therapy according to the age of nursing students.
Table 6. Relationship between the perceptions on the effectiveness of
milieu therapy to patients according to the age of nursing students
AGE
EFFECTIVENESS OF MILIEU THERAPY

Highly
Effective
17 21
22
26
27
32
Total
=
7.1744
= 4
Finding: Not significant
9
2
0
11
Moderately
Effective
FREQUENCY
Effective
14
64
15
69
41
1
1
43
= 9.488
= 5%
No significant relationship was found between age the nursing studentrespondents perception on the effectiveness of milieu therapy to mental patients
as shown in Table 6. The computed chi-square value of 7.1744 was remarkably
less than the critical value of 9.488 at five percent level of significance. Hence,
the null hypothesis of insignificant relationship was accepted. This suggests that
age did not significantly influence the nursing student-respondents perception on
the effectiveness of milieu therapy to mental patients. This also indicates that the
perception of the respondents is generally the same whether they belong to the
youngest or older age bracket.
Gender and Perception on the Effectiveness of Milieu Therapy

effectiveness of milieu therapy according to the gender of nursing students.
milieu therapy to patients according to the gender of nursing students
GENDER

Highly
Effective
Male
Female
Total
=
2.7906
= 2
3
8
11
Moderately
Effective
8
35
43
FREQUENCY
Effective
17
9
15
52
69
= 5.991
= 5%
The above table shows that, at 5% level of significance and with 2 degree
of freedom,
no significant relationship was found between gender and the
nursing student-respondents perception on the effectiveness of milieu therapy to

mental patients. The computed chi-square value of 2.7906 was lower than the
critical value of 5.991. The null hypothesis, is therefore, accepted. This implies
that gender did not have considerable influence on the perception of the
respondents on the effectiveness of milieu therapy to mental patients. Gender
roles may vary from culture to culture and many of the behavioral and
psychological differences between genders were caused by socialization as well
as hormonal causes. Still similarity may still occur in their behaviors and
psychological outlook (Microsoft Encarta Encyclopedia, 2009). Thus, the
perception of the respondents on the effectiveness of milieu therapy to mental
patients is generally homogenous even when grouped according to gender.
Birth Order and Perception on the Effectiveness of Milieu Therapy

effectiveness of milieu therapy according to the birth order of nursing students.

milieu therapy to patients according to the birth order of the nursing students
BIRTH
ORDER

Highly
Effective
Moderately
Effective
28
12
2
11
3
43
1st
2nd
3rd
4th
5th
7th
Total
=
6.6686
= 4
FREQUENCY
Effective
40
20
15
69
= 9.488
= 5%

Table 8 shows that no significant relationship exists between births order
the nursing students perceptions on the effectiveness of milieu therapy to mental
patients. The computed chi-square value of 6.6686 was much lower than the
critical value of 9.488 at 5 percent level of significance. The hypothesis
suggesting that there is no significant relationship between the profile of the
nursing students and their perceptions as to the effectiveness of milieu therapy to
patients and is therefore not rejected. The result suggests that sibling position of
the respondents did not have substantial influence on their perception on the
effectiveness of milieu therapy to patients. The respondents perceptions are,
therefore, not dependent on whether the respondent is the youngest or the oldest
child in the family.
Types of Therapy Practiced and Perception on the Effectiveness of

Milieu Therapy
effectiveness of milieu therapy according to the types of therapy practiced by the
nursing students.
milieu therapy to patients according to the types of therapy practiced by the
nursing students
FORMS OF THERAPY
PRACTICED
EFFECTIVENESS OF MILIEU
THERAPY
Highly
Effective
Art, music, dancing,

play/games, food
preparation/cooking
Music, dancing,
play/games
Play/games
Art, music, play/games
Total
=
3.8612
= 6
Moderately
Effective
10
39
FREQUENCY
Effective
15
0
64
1
0
1
2
1
0
0
2
2
11
43
15
69
= 12.592
= 5%
Table 9 shows that no significant relationship was found between forms of

therapy practiced and the perception of the nursing student-respondents on the
effectiveness of milieu therapy to mental patients. The computed chi-square
value of 3.8612 was considerably lower than the critical value of 12.592 at 5
percent level of significance. This shows that, in general, the perceptions of the
respondents on the effectiveness of milieu therapy as a form of treatment to
mental patients are similar. This maybe because, as apprentices who employed
these therapeutic treatments to the patients, their point of views on the
effectiveness of milieu therapy are influenced by their nursing training, above all
else (Hamada, et., 2008). Thus, their perceptions on the effectiveness of the
milieu therapy are, more likely, based on clinical observation rather than personal
opinion (Varcarolis, 1990). Moreover, a well-trained staff representing a
comprehensive array of professional skills produces the best outcomes when
they work together. When all staff are trained in one approach that includes the
philosophy, training, mission and intervention methods of the program one would
expect the same outcomes for patients (Zummo, 2007)
Chapter Five
SUMMARY, FINDINGS, CONCLUSION AND RECOMMENDATION
This chapter shows the logical flow of this study, summary, findings,
conclusions and recommendations as answers to the problems identified.
Summary
The primary objective of this study is to determine the effectiveness of
milieu therapy to patients as perceived by the nursing students assigned at the
Cavite Center for Mental Health. More specifically, the study sought to answer
the following questions:
4.1 Age
4.2 Gender
4.3 birth order
4.4 types of therapy practiced
The hypothesis of the study was: There is no significant relationship
between the demographic profile of the nursing students and their perception on
the effectiveness of milieu therapy to mental patients at the Cavite Center for
Mental Health.
In order to obtain the needed information as to the abovementioned

questions, the researchers used the descriptive research design. A survey
questionnaire was constructed and then utilized the same to attain the
objectives of this study. A total of 69 nursing students from Emilio Aguinaldo
College in Dasmarinas, Cavite who were assigned at the Cavite Center for
Mental Health were made respondents for this study. Data gathering was made
from October to November 2009.
Majority or 64 respondents (92.75%) have ages ranging from 17 to 21
years; followed by 3 respondents (4.35%) belonging to the 22 to 26 years old age
bracket and 2 respondents (2.90%) belonging to the oldest age bracket of 27 to
32 years. Majority or 52 respondents (75.36%) are female and only 17 (24.64%)
are male. More than half of the respondents (57.97%) are either 1 st or 2nd in birth
order obtaining rank number one, followed by 20 respondents (28.99%) who
were either the 3rd or 4th child. Third in rank were 9 nursing student-respondents
(13.04%) who were
either the 5 th, 6th or 7th child in the family. Almost all
respondents (92.75%) applied art, music, play/games, dancing and food

preparation/cooking; 2 nursing students (2.90%) practiced only play/games
therapy and another 2 respondents (2.90%) practiced music, dancing,
play/games. Only one respondent (1.45%) practiced the combination of art,
music and play/games forms of milieu therapy to patients.
Rating the effectiveness of milieu by using the scores generated from the
Likert Scale, 11 respondents (15.94%) perceived milieu therapy as a highly
effective type of treatment to mental patients; 43 respondents or majority of the
nursing students (62.32%) perceived the same as a moderately effective; while

the remaining 15 respondents (21.74%) perceived milieu therapy as an
effective treatment to mental patients. None of the nursing students perceived
milieu therapy as a not so effective or ineffective form of treatment to patients.
Using chi-square test, no significant relationship was found between the
demographic profile of the nursing students and their [perceptions on the
effectiveness of milieu therapy to patients.
Findings
1. The following are the findings of the study:
1.1. Sixty-four nursing students have ages ranging from 17-21 years
representing 92.75% of the respondents.
1.2. Majority or 52 nursing students are female, dominating the
percentage share (75.36%) of the respondents when it comes to
gender.
1.3. More than half of the respondents (40) or 57.97% are either 1 st or
2nd in birth order.
1.4. Almost all respondents (64) or 92.75% practiced the following
types of milieu therapy: art, music, play/games, dancing and food
preparation/cooking
2. Majority or 43 nursing students (62.32%) perceived milieu therapy as a
moderately effective type of treatment to patients at the Cavite Center
for Mental Health.
3. The hypothesis pursued in this study are as follows:
3.1. At five percent (5%) level of significance with 4 degrees of
freedom, the computed chi-square value of 7.1744 was
remarkably lower than the critical value of 9.488. The null
hypothesis is accepted. Therefore, there is no significant

relationship between age and the nursing students perception on
the effectiveness of milieu therapy to patients.
freedom, the computed chi-square value of 2.7096 was lesser
than the critical value of 5.991. The null hypothesis is accepted.
Therefore there is no significant relationship between gender and
the nursing students perception on the effectiveness of milieu
therapy to patients.
freedom, the computed chi-square value of 6.6686 was lesser
than the critical value of 9.488. The null hypothesis is accepted.
Hence, there is no significant relationship between birth order and
the nursing students perception on the effectiveness of milieu
therapy to patients.
freedom, the computed chi-square value of 3.8612 was
significantly lower than the critical value of 12.592. The null
hypothesis is accepted. Therefore, there is no significant
relationship between types of therapy practiced and the nursing
students perception on the effectiveness of milieu therapy to
patients.
Conclusions
Based on the findings of the study, the researchers arrived at the following
conclusions:
4. The nursing student-respondents were mostly 17 to 21 years old; the

number of female being a lot greater than male respondents; usually
1st or 2nd in sibling position and were able to practice all types of milieu
therapy to patients at the Cavite Center for Mental Health.
5. Majority of the respondents perceived milieu therapy as a moderately
effective type of treatment to patients at the Cavite Center for Mental
Health.
6. There is no significant relationship between the demographic profile of
the nursing students and their perceptions on the effectiveness of
milieu therapy to patients at the Cavite Center for Mental Health.
Recommendations
In lieu of the abovementioned conclusions, the following recommendations
are proposed:
4. School of Nursing and Midwifery. The clinical instructors and faculty
members of the School of Nursing and Midwifery should consider the
findings of this study to enhance the their supervisory skills and
improved their method of instructions so that they would be able to
educate and guide the students along the different aspects of the
nursing profession; enabling them to become well trained, competent,
skillful and competitive nurses in the future.
Efforts should also be made by the School of Nursing and
Midwifery to enhance the Nursing curriculum directed towards enabling
the students to undertake hospital duties at various mental facilities to
expose and train them on the different methods of treatment for mental
patients and conduct more responsibilities as nursing apprentices to
build up their care-giving attitudes to improve their nursing skills and
competencies and develop their
social and behavioral attitudes
towards peers and patients alike

5. Student Nurse. The student nurse involved in the study should take
some initiative to learn the skills, theories and skills involved in the
conduct of a particular learning program so that he/she can put her
knowledge into practice. Thereby becoming a capable representative
of her field to help and assist in medical and nursing services in the
community.
6. Future researches should be explored through replication or expansion
of this study allowing for a better representation of demographics to
include such characteristics as the students Grade Point Average
(GPA) and exposure to other treatments for mental patients. Likewise,
future studies utilizing students from other colleges and universities
offering the same program should be considered.
SURVEY QUESTIONNAIRE
Effectiveness of Milieu Therapy to Mental Patients as Perceived by Nursing
Students Assigned at the Cavite Mental Health Center
Name: _______________________________________________
Section: ________________
I.
Demographic Profile
1. Age: _______
2. Gender:
_______
_______
Male
Female
3. Birth order:
_______
1st
_______
2nd
_______
3rd
_______
4th
_______
5th
Others, please specify __________________
4. Types of Milieu Therapy Practiced:
_______
art
_______
singing
_______
dancing
_______
play or games
_______
food preparation and cooking
II.
Effectiveness of Milieu Therapy

Instructions: Please answer each item truthfully. Base your answers solely
from your observations of the emotional, social and behavioral status of the
mental patients after undergoing milieu therapy. Refrain from soliciting opinions
from classmates or hospital staff assigned at the facility. Use the 5-Point Likert
Scale below to guide you in answering the questions on the following pages:
5
always
4
often
3
sometimes
2
seldom
1
never
Observations
A. Emotional Status
1) Manifest signs of gaining hope and inspiration
2) Feels acceptance and belongingness by
seeking/wanting companionship/friendship of others
3) Seems to be aware that she/he is not alone
4) Exhibit decreased levels of anxiety
5) Seems able to resolve conflicts/problems on her/his own
B. Social Status
1) Willingly participates in milieu therapy sessions
2) Develops important interpersonal skills
3) Starts to express personal feelings openly and directly
to others
4) Maintains and initiates good grooming
5) Show signs of improvement on general appearance
C. Behavioral Status
5 4 3 2
1) Appears to be free from delusions and hallucinations

2) Interacts with reality-based topics and interactions
3) Observed to be free from any physical/bodily injury (selfinflicted)
4) Does not exhibit negative/aggressive behaviors
5) Sustains concentration and attention to complete task or
activity at hand
Interpretation of Scores:
61 75
- highly effective
46 60
- moderately effective
31 45
- effective
16 30
- not so effective
0 15
- not effective
BIBLIOGRAPHY
A. Books
Aquino, D. R. C. and R. T. Dasil. 2003. The Philippine Nursing Act of 2002.
Quezon City: Rex printing Company, Inc.
Kozier, B., G. Erb, A. Berman and S.J. Snyder. 2004. Fundamentals of Nursing:
Concepts, Process and Practice. Seventh Edition. Pearson Education Inc.,
Upper Saddle River, New Jersey
Varcarolis, E.M. 1990. Foundations of Psychiatric Mental Health Nursing. New
York: W.B. Saunders Company
B. Journals/Bulletins
American Music Therapy Association, Inc. 2009. Frequently Asked Questions
About Music Therapy. Retrieved from: http://www.musictherapy.org/faqs.,
July 25, 2009
Borgea, L. and Fagermoenba, M. S. 2007. Wholeness and self-worth in time and

space. Hedmark University College, Faculty of Health and Sports,
Vikersundb Aker University Hospital & University of Oslo, Institute of
Nursing and Health Sciences, Oslo, Norway. Retrieved from:
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Ciompi, L. and Hoffmann, H. 2004. Conceptual Bases of Soteria Berne:
Therapeutic Consequences and Their Practical Realization in Soteria
Berne Clinical Observations. Sectorized Community Psychiatry
Department, Berne University Hospital of Social and Community
Psychiatry, Berne, Switzerland. Copyright World Psychiatric Association.
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Conde, B. 2004. Philippines Mental Health Country Profile. International Review
of Psychiatry 16(12), 159166. University Press. University of Santo
Tomas, Espaa, Manila
Delaney, K.R. 2006. Top 10 Milieu Interventions for Inpatient Child/Adolescent
Treatment. Journal of Child and Adolescent Psychiatric Nursing. Retrieved
from: http://findarticles.com/p/articles/, July 09, 2009
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and Other Severe Mental Disorders: Uncovering the attitudes of
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treatments for children and adolescents with disruptive behavior. Journal
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EFFECTIVENESS OF MILIEU THERAPY TO PATIENTS AS PERCEIVED

BY THE NURSING STUDENTS ASSIGNED AT THE

An Undergraduate Research Proposal

EFFECTIVENESS OF MILIEU THERAPY TO PATIENTS AS

Maria Lailani D. Llamas RM, RN

This study aimed to determine the effectiveness of milieu therapy to

2. What are the perceived effects of milieu therapy to mental patients?

Majority or 43 nursing students (62.32%) perceived milieu therapy as a

Efforts should also be made by the School of Nursing and

social and behavioral attitudes

towards peers and patients alike

Background of the Study

Figure1. The Variables and their Relationship

Statement of the Problem

In this study, the effectiveness of milieu therapy to mental patients as

Scope and Delimitation

It covered a total of 69 nursing student-respondents from Emilio Aguinaldo

Significance of the study

workers/personnel and professionals, government officials, the College, and

understanding of the study:

Refers to the efficiency or usefulness of using milieu

effective, not so effective or not effective.

Refer to the patients presently undergoing milieu

In this research, this will be limited to art, singing,

Refer to fourth year nursing student-respondents from

effectiveness milieu therapy to mental patients based

This chapter presented a review and survey of related literature. To gather

issues include such concepts as mens rea,

sane and insane automatism

for compulsory treatment in a psychiatric hospital or in the community. In

jurisdictions court orders are required for compulsory treatment while in

others treating psychiatrists may treat compulsorily by following set procedures.

disaster/emergency preparedness plan for mental health. The present national

therapeutic drug policy/essential list of drugs in the country was formulated in

Since music therapists serve a wide variety of persons with many

different types of needs there is no such thing as an overall typical session.

comparable daily costs. Basic concepts, practical proceedings and empirical

The World Health Organizations Mental Health Atlas (2005), however,

In relation to this, Reyes et al (2007) likewise revealed that 48 percent of

education and professional development. Academic institutions and training

resources, specifically psychiatrists,

psychologists, social workers, nurses and allied mental health professionals.

These results are similar to those reported by other

private institutions. A comparison to traditional psychiatric treatment approach

done in Helsinki, Finland, of 141 clients yielding, only 2% remained totally

Justification of the Study

experiences for their recovery processes using qualitative interviews with 15

therefore to ascertain if milieu is indeed an effective treatment from the

Population and Sampling

Validity and Reliability of the Instrument

Data Gathering Procedure

questionnaires were gathered and checked for completeness a week after

Statistical Treatment of Data

- total number of respondents

- the size of the sample

N - the size of the population

WtdX - the weighted mean

total number of respondents

PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

This chapter deals with the presentation, analysis and interpretation of

As seen on Table 1, the age of the nursing student-respondents ranged

The above table shows that of the 69 student nursing-respondents, 52 or

combination of art, music and play/games as forms of milieu therapy to mental