Presentation

on
Therapeutic milieu

MODERATOR: PRESENTED BY:

DR. SUNITA SHARMA SHAILJA SHARMA
LECTURER M.SC. (N) 2ND YEAR
NINE,PGIMER, NINE, PGIMER,
CHANDIGARH CHANDIGARH
 INTRODUCTION
• The word milieu is French in origin which stands for
“middle.” The English translation of the word is
“surroundings, or environment.”
• The goal of milieu therapy is to manipulate the
environment so that all aspects of the client’s
hospital experience are considered therapeutic.
Within this therapeutic community setting the client
is expected to learn adaptive coping, interaction,
and relationship skills that can be generalized to
other aspects of his or her life.
DEFINITION

• Milieu Therapy: A
scientific structuring of
the environment in order
to effect behavioural
changes and to improve
the psychological health
and functioning of the
individual (Skinner,
1979).
 CURRENT STATUS OF THE THERAPEUTIC
COMMUNITY
• Milieu therapy came into its own during the
1960s through early 1980s. During this period,
psychiatric inpatient treatment provided
sufficient time to implement programs of
therapy that were aimed at social
rehabilitation.
• Patients were encouraged to be active
participants in their therapy, and individual
autonomy was emphasized.
 CURRENT STATUS OF THE THERAPEUTIC
COMMUNITY
• Now strategies for milieu therapy have been
modified to conform to the short-term
approach to care or to outpatient treatment
programs.
• Echternacht (2001) suggests that more
emphasis should be placed on unstructured
components of milieu therapy.
 CURRENT STATUS OF THE THERAPEUTIC
COMMUNITY
• She describes the unstructured components as a
multitude of complex interactions between clients, staff,
and visitors that occur around the clock. Echternacht calls
these interactions “fluid group work.”
• With fluid group work, the nurse applies
psychotherapeutic knowledge and skills to brief clinical
encounters that occur spontaneously in the therapeutic
milieu setting. Echternacht (2001) believes that by using
these techniques, nurses can “reclaim their milieu therapy
functions in the midst of a changing health care
environment”.
 PURPOSES

It had two main purposes:

• To set limits on disturbing and maladaptive
behaviour
• To teach psychosocial skills
• Develop adaptive coping
• Achieving client autonomy
• Acquire interpersonal and stress management skills.
• Correct the redefine perception of stressor
 MANAGING DISTURBING BEHAVIOUR IN
THE MILIEU
• Destructiveness
The goal is to control or set limits on the
maladaptive response but support the feeling
underlying the behaviour. Validation is
essential to help the patient recognize the
feelings and ultimately regain control of
maladaptive behaviour.
• Disorganization
Reassure and help the patient while reducing
the degree to which these behaviours inhibit
therapeutic process.
• Deviancy
The therapeutic goal here is to analyze how the
behaviour affects the milieu ad how it inhibits
patient’s progress. Examining the behaviour
with the patient and indentifying consequences
and alternatives are useful approaches.
• Dysphoria
Establish therapeutic alliance and from here
nurse ad patient ca explore feelings and
dysfunctional thoughts and begin to modify
responses.
• Dependence
the initial therapeutic goal is to identify the
remaining areas of independence and strength.
Then situations can be identified in which patient
can apply these independent behaviours
successfully.
 PURPOSES

After maladaptive behaviours are limited, the therapeutic

milieu can be used to develop the following four important
psychosocial skills in mentally ill patients:

1. Orientation. Orientation is the patient’s knowledge and

understanding of time, place, person, and purpose.
Awareness of these elements can be reinforced through
patient interactions and activities such as introducing
oneself and rationale for a interaction, community
meetings to explain unit structure and answer patient
questions in a group setting; and discussions of current
events.
 PURPOSES
2. Assertion: The ability to express oneself
appropriately can be role-modelled and exercised
in a variety of ways in the treatment setting.
Supporting patients in expressing themselves
effectively and in a socially acceptable manner on
a specific topic or issue is the overall goal.
Sample interventions include assertiveness
training, anger management groups, and focus
groups for lower-functioning patients.
 PURPOSES
3. Occupation: Patients can feel a sense of
confidence and accomplishment through
industrious activity. Spending time working
with patients on something as simple as a
jigsaw puzzle can provide purposeful activity,
physical skill development, and the added
benefit of practiced social interaction.
 PURPOSES
4. Recreation. The ability to engage in and
enjoy leisure time is a beneficial outlet for
pleasure and relaxation. Providing a variety of
recreational opportunities helps patients
apply many of the skills they have learned,
including orientation, assertion, social
interaction, and physical dexterity.
 BASIC ASSUMPTIONS
Skinner (1979) outlined seven basic assumptions on which a
therapeutic community is based:
1. The Health in Each Individual Is to Be Realized and Encouraged to
Grow.
All individuals are considered to have strengths as well as limitations.
These healthy aspects of the individual are identified and serve as a
foundation for growth in the personality and in the ability to function
more adaptively and productively in all aspects of life.
2. Every Interaction Is an Opportunity for Therapeutic Intervention.
Within this structured setting, it is virtually impossible to avoid
interpersonal interaction. The ideal situation exists for clients to
improve communication and relationship development skills. Learning
occurs from immediate feedback of personal perceptions.
 BASIC ASSUMPTIONS

3. The Client Owns His or Her Own Environment.

Clients make decisions and solve problems related to
government of the unit. In this way, personal needs for
autonomy as well as needs that pertain to the group as
a whole are fulfilled.
4. Each Client Owns His or Her Behaviour
Each individual within the therapeutic community is
expected to take responsibility for his or her own
behaviour.
5. Peer Pressure Is a Useful and a Powerful Tool
Behavioural group norms are established through peer
pressure. Feedback is direct and frequent, so that behaving in a
manner acceptable to the other members of the community
becomes essential.
6. Inappropriate Behaviours Are Dealt with as They Occur.
Individuals examine the significance of their behaviour, look at
how it affects other people, and discuss more appropriate ways
of behaving in certain situations.
7. Restrictions and Punishment Are to Be Avoided.
Destructive behaviours can usually be controlled with group
discussion. However, if an individual requires external controls,
temporary isolation is preferred over lengthy restriction or
other harsh punishment.
 CONDITIONS THAT PROMOTE A
THERAPEUTIC COMMUNITY
• In a therapeutic community setting, everything that
happens to the client, or within the client’s environment,
is considered to be part of the treatment program. The
community setting is the foundation for the program of
treatment. A number of criteria have been identified:
1. Basic Physiological Needs Are Fulfilled. As Maslow
(1968) has suggested, individuals do not move to higher
levels of functioning until the basic biological needs for
food, water, air, sleep, exercise, elimination, shelter, and
sexual expression have been met.
2. The Physical Facilities Are Conducive to Achievement of the
Goals of Therapy. Space is provided so that each client has
sufficient privacy, as well as physical space, for therapeutic
interaction with others. Furnishings are arranged to present a
homelike atmosphere—usually in spaces that accommodate
communal living, dining, and activity areas— for facilitation of
interpersonal interaction and communication.
3. A Democratic Form of Self-Government Exists. In the
therapeutic community, clients participate in the decision
making and problem solving that affect the management of
the treatment setting. This is accomplished through regularly
scheduled community meetings. These meetings are
attended by staff and clients, and all individuals have equal
input into the discussions. At these meetings, the norms and
rules and behavioural limits of the treatment setting are set
forth.
4. Responsibilities Are Assigned According to Client
Capabilities. Increasing self-esteem is an ultimate goal of the
therapeutic community. Therefore, a client should not be set
up for failure by being assigned a responsibility that is beyond
his or her level of ability. By assigning clients responsibilities
that promote achievement, self-esteem is enhanced.
5. A Structured Program of Social and Work-Related Activities Is
Scheduled as Part of the Treatment Program. Each client’s
therapeutic program consists of group activities in which
interpersonal interaction and communication with other
individuals are emphasized. Time is also devoted to personal
problems. Through these activities, change in the client’s
personality and behaviour can be achieved. New coping
strategies are learned and social skills are developed. In the
group situation, the client is able to practice what he or she
has learned to prepare for transition to the general
community.
6. Community and Family Are Included in the
Program of Therapy in an Effort to Facilitate
Discharge from Treatment. An attempt is made to
include family members, as well as certain aspects
of the community that affect the client, in the
treatment program. Family members are invited to
participate in specific therapy groups and, in some
instances, to share meals with the client in the
communal dining room. These connections with
family and community facilitate the discharge
process and may help to prevent the client from
becoming too dependent on the therapy.
 FUNCTIONS OF THERAPEUTIC MILIEU
• Containment.
• Containment refers to providing for the physical well-being of
patients. It includes provision of food, shelter, and medical
attention, as well as taking the steps necessary to prevent the
patient from harming self or others. It includes a continuum of
interventions, with the use of seclusion and restraints being the
most extreme. Containment interventions should be evaluated
using the philosophy of least-restrictive measures required to
ensure safety. Appropriate use of therapeutic containment
strategies provide safety and foster trust. Nurses should engage in
self-evaluation and constructive feedback with peers to be sure
that containment strategies are based on response to patient
behaviours and not staff needs or frustration.
 FUNCTIONS OF THERAPEUTIC MILIEU

• Support.
• Support refers to the staff’s conscious efforts to help
patients feel better and enhance their self-esteem. It
involves providing sanctuary and unconditional
acceptance of the patient. The function of support is to
help patients feel more secure and less anxious. Support
can be communicated by being available, appropriately
offering encouragement and reassurance, giving helpful
direction and explanations, offering food or beverages,
and taking time to engage patients in therapeutic
conversation and activities.
 FUNCTIONS OF THERAPEUTIC MILIEU

• Structure.
• Structure refers to all aspects of a milieu that
provide a predictable organization of time,
place, and person. Dependability of the
environment helps patients feel safe and
control maladaptive behaviours. Providing a
daily schedule for groups, rounds, meals, and
medications, as well as fostering an expectation
of participation are examples of structure.
 FUNCTIONS OF THERAPEUTIC MILIEU

• Involvement.
• Involvement refers to processes that help patients
actively attend to their social environment and
interact with it. The purpose is to modify
maladaptive interpersonal patterns. Programs that
emphasize involvement encourage the use of
cooperation, compromise, and confrontation.
 FUNCTIONS OF THERAPEUTIC MILIEU

• Validation.
• Validation refers to the recognition of the
individuality and value of each patient. It affirms a
person’s unique world view. The psychiatric nurse
communicates this through individual attention,
empathy, and nonjudgmental acceptance of the
patient’s thoughts, feelings, and perspective.
 THE PROGRAM OF THERAPEUTIC
COMMUNITY
• Care for clients in the therapeutic community is
directed by an interdisciplinary treatment (IDT)
team. An initial assessment is made by the
admitting psychiatrist, nurse, or other designated
admitting agent who establishes a priority of care.
The IDT team determines a comprehensive
treatment plan and goals of therapy and assigns
intervention responsibilities. All members sign the
treatment plan and meet regularly to update the
plan as needed.
 THE INTERDISCIPLINARY TREATMENT
TEAM IN PSYCHIATRY
• Psychiatrist
 Serves as the leader of the team. Responsible for
diagnosis and treatment of mental disorders.
Performs psychotherapy; prescribes medication and
other somatic therapies.
• Clinical psychologist
 Conducts individual, group, and family therapy.
Administers, interprets, and evaluates psychological
tests that assist in the diagnostic process.
 THE INTERDISCIPLINARY TREATMENT TEAM IN PSYCHIATRY

• Psychiatric clinical nurse specialist

 Conducts individual, group, and family therapy. Presents
educational programs for nursing staff. Provides consultation
services to nurses who require assistance in the planning and
implementation of care for individual clients
• Psychiatric nurse
 Provides ongoing assessment of client condition, both
mentally and physically. Manages the therapeutic milieu on a
24-hour basis. Administers medications. Assists clients with
all therapeutic activities as required. Focus is on one-to-one
relationship development
 THE INTERDISCIPLINARY TREATMENT TEAM IN PSYCHIATRY

• Mental health technician (also called psychiatric aide or assistant

or psychiatric technician)
 Functions under the supervision of the psychiatric nurse. Provides
assistance to clients in the fulfilment of their activities of daily living.
Assists activity therapists as required in conducting their groups.
May also participate in one-to-one relationship development.
• Psychiatric social worker
 Conducts individual, group, and family therapy. Is concerned with
client’s social needs, such as placement, financial support, and
community requirements. Conducts in-depth psychosocial history
on which the needs assessment is based. Works with client and
family to ensure that requirements for discharge are fulfilled and
needs can be met by appropriate community resources
 THE INTERDISCIPLINARY TREATMENT TEAM IN PSYCHIATRY

• Occupational therapist
 Works with clients to help develop (or redevelop)
independence in performance of activities of daily living. Focus
is on rehabilitation and vocational training in which clients
learn to be productive, thereby enhancing self-esteem.
Creative activities and therapeutic relationship skills are used.
• Music therapist
 Encourages clients in self-expression through music. Clients
listen to music, play instruments, sing, dance, and compose
songs that help them get in touch with feelings and emotions
that they may not be able to experience in any other way.
 THE INTERDISCIPLINARY TREATMENT TEAM IN PSYCHIATRY

• Recreational therapist
 Uses recreational activities to promote clients to redirect
their thinking or to re-channel destructive energy in an
appropriate manner. Clients learn skills that can be used
during leisure time and during times of stress following
discharge from treatment.
• Art therapist
 Uses the client’s creative abilities to encourage expression
of emotions and feelings through artwork. Helps clients to
analyze their own work in an effort to recognize and
resolve underlying conflict.
 THE INTERDISCIPLINARY TREATMENT TEAM IN PSYCHIATRY

• Psycho dramatist
 Directs clients in the creation of a “drama” that portrays
real-life situations. Individuals select problems they wish
to enact, and other clients play the roles of significant
others in the situations. Some clients are able to “act
out” problems that they are unable to work through in a
more traditional manner.
• Dietician
 Plans nutritious meals for all clients. Works on consulting
basis for clients with specific eating disorders, such as
anorexia nervosa, bulimia nervosa, obesity, & pica
 THE INTERDISCIPLINARY TREATMENT TEAM IN PSYCHIATRY

• Chaplain
 Assesses, identifies, and attends to the
spiritual needs of clients and their family
members. Provides spiritual support and
comfort as requested by client or family. May
provide counseling if educational background
includes this type of preparation
 THE ROLE OF THE NURSE

• Milieu management is an important activity of the

psychiatric nurse and requires a deliberate decision-
making process. It is essential that psychiatric nurses
working in structured settings realize the potential
positive or negative impacts that the environment can
have on the patient (Shattell et al, 2008). The psychiatric
nurse should first assess patient needs within the context
of the needs of the larger patient group. Weighing
individual needs against group needs can be difficult, but
it is necessary for the successful implementation of a
therapeutic milieu.
The nurse can then engage aspects of the therapeutic milieu
to meet these needs by providing the following:
• Physical safety and well-being without barriers to
interaction (containment)
• Education about the patient’s individualized treatment and
safety plan (support)
• Therapeutic and predictable activity schedules that reduce
boredom (structure)
• Opportunities for social interaction to prevent isolation
(involvement)
• Acknowledgment of the patient’s feelings to foster respect
and trust (validation)
 1) Patient Safety and Risk Reduction
• Ensuring patient safety and risk reduction begins with a thorough
risk assessment on admission and throughout the course of
treatment.
• Common areas of safety risk for psychiatric inpatients include
potential for aggression or violence, suicide attempts, adverse
medication reactions, elopement, seizures, falls, allergic reactions,
and communicable diseases.
• Effective management strategies that can be used to keep units safe
include knowing each patient, noticing the beginning of an episode,
regularly documenting risk assessments, and awareness of the
climate and tensions within the unit.
• Implementation of safety precautions includes enacting the
prescribed nursing care and explaining the assessed risk and
precautions to the patient and other caregivers so that everyone is
working together to keep the patient safe.
 2) Meeting Physical Needs

• Completion of a physical assessment on admission

and monitoring the patient’s physical status
throughout the hospitalization are essential functions
of the psychiatric nurse.
• Nurses must be vigilant in the ongoing assessment
and management of environmental risks to all patients
in the milieu to prevent adverse outcomes.
• Patients at risk for self-harm and aggression require
special monitoring considerations when they also are
being treated for medical illnesses.
 3) Patient and Family Education

• The process of education begins with an assessment of the

patient’s strengths, readiness, and barriers to learning. Such
barriers may include lack of insight or denial related to the
illness, low level of literacy, sensory deficits such as visual or
hearing impairments, limited concentration and attention
span, confusion, or impaired memory.
• Repetition, presenting information in ways that engage
multiple sensory avenues, and providing opportunities for
practice and feedback promote learning for psychiatric
patients.
• Common topics for education include symptom recognition
and management, medication education, relapse prevention,
and discharge plans.
 3) Activities, Groups, and Programs
• Therapeutic activities, groups, and programs provide
opportunities for the nurse to influence the patient’s progress
toward treatment goals throughout the hospital stay. The
challenge is to plan these events in a way that integrates
patients’ interests and abilities with desired patient outcomes.
• Therapeutic groups and programs provide a cost- effective way
to implement psychiatric nursing care. Patients are encouraged
to participate as they show readiness to tolerate the
intervention especially in the acute care setting. Assessment of
the patient before, during, and after group experiences offers
important information for diagnosis and treatment planning.
Care should be taken to make sure that the group is
appropriate for each patient to prevent confusion, frustration,
and isolation.
 4) Discharge Planning
• Discharge planning is a process that begins on admission.
The nurse must assess the patient’s environment and
identify potential needs and resources.
• After the nurse has assessed what knowledge and skills
can help the patient adapt successfully on discharge,
planning begins for education and skill development.
• A discharge checklist can be used as an interdisciplinary
tool to review the patient’s discharge needs, including
the patient in every step of the planning process. Areas
of discharge planning include medications, activities of
daily living, ongoing comprehensive health care, housing,
and financial assistance.
 5) Team work and coordinated care

• To integrate and coordinate patient care,

nurses must collaborate with professionals
from other disciplines and manage a group of
nursing care providers.
• Team communication must be open and active
and the contribution of each team member
must be valued and respected.
 6) Resource allocation

• Psychiatric nurses must be able to justify the

type ad level of nursing personnel needed to
provide high quality nursing care.
• The assignment of nursing resources must be
based on identified patient care needs, clinical
competencies and available resources.
 7) 0thers

• Reality orientation
• Medication administration
• Setting limits on unacceptable behaviour.
 Advantages of milieu
• It develops a leadership skills
• Patient learns making decisions which improve
his confidence.
• Patient develops harmonious relationships with
other members in therapeutic community
• Learns to understand and solve problems of self
and others
• Becomes socio- centric.
 Disadvantages
• Role blurring between staff and patient.
• Limited to in patient only
• Requires continuous open communication
among all staff and clients
• Group responsibility can easily becomes
nobody’s responsibility
• Low client- to- staff ratio.
 Conclusion
• Milieu therapy has been described as an
excellent framework for operationalizing
Peplau’s interpretation and extension of Harry
Stack Sullivan’s Interpersonal theory for use in
nursing practice.
• Nurses need to identify the number if RNs
necessary to carry out structured and
unstructured milieu functions consistent with
their standards of practice.
 REFERENCES

• Mary C. Townsend (2012) “Psychiatric mental

health nursing”. 7th edition, Jaypee
publications, New Delhi
• Varcarolis Elizabeth M; Foundations of
psychiatric mental health nursing. 3rd
edition,W.B. Saunders company.
• Stuart Gail W. “Principles and Practice of
Psychiatric nursing”. 10th edition, Elsevier
publications.