MILIEU

THERAPY /
THERAPEUTIC
COMMUNITY
 Objective of the
•session
Define milieu therapy.
• Explain the goal of therapeutic
community/milieu therapy.
• Identify seven basic assumptions of a
therapeutic community.
• Discuss conditions that characterize a
therapeutic community.
• Identify the various therapies that may be included
within the program of the therapeutic community
and the health-care workers that make up the
interdisciplinary treatment team.
• Describe the role of the nurse on the
interdisciplinary treatment team.
 Standards of psychiatric nursing (standard
•5C)
“The psychiatric-mental health nurse provides, structures,
and maintains a safe and therapeutic environment in
collaboration with patients, families, and other health care
clinicians”
 Meanin
•gThe word milieu is French for “middle.” The English translation of
the word is “surroundings, or environment.” In psychiatry,
therapy involving the milieu, or environment, may be called
milieu therapy, therapeutic community, or the therapeutic
environment.
 Goal of the
•therapy
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
• 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 behavioral changes and to improve the
psychological health and functioning of the individual (Skinner,
1979).
Historical
aspects
• Milieu therapy came into its own during the 1960s through
the early 1980s.
• During this period, psychiatric inpatient treatment provided
sufficient time to implement programs of therapy that were
aimed at social rehabilitation.
• Nursing’s focus of establishing interpersonal relationships
with clients fit well within this concept of therapy.
• Patients were encouraged to be active participants in
their therapy, and individual autonomy was emphasized.
 Basic assumptions of the therapeutic
•community
Skinner (1979) outlined seven basic assumptions on which
a therapeutic community is based:

• Assumption 1
• 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.
 Assumption
•22. 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.
• Assumption
3

• 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.
• Assumption 4
• 4. Each client owns his or her behavior: Each individual within the
therapeutic community is expected to take responsibility for his
or her own behavior.
• Assumption 5
• 5. Peer pressure is a useful and powerful tool:
Behavioral 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.

• Assumpti0n 6
• 6. Inappropriate behaviors are dealt with as they
occur: Individuals examine the significance of
their behavior, look at how it affects other
people, and discuss more appropriate ways of
behaving in certain situations.
 Assumption
•77. Restrictions and punishment are to be avoided: Destructive
behaviors can usually be controlled with group discussion.
However, if an individual requires external controls,
temporary isolation is preferred over lengthy restriction or
other harsh consequences.
Conditions that promote a
therapeutic community
• 1. Basic physiological needs are
fulfilled:

• 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.
Cont
. government exists: In the
• 3. A democratic form of self-
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.

• 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.
Cont
.
• 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.

• 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.
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
Cont.
.
Intervention responsibilities

All members sign the treatment plan and meet regularly to update
the
plan as needed.

Depending on the size of the treatment facility and scope of the

therapy program, members representing a variety of disciplines may
participate in the promotion of a therapeutic community
Members of the Inter Disciplinary
team
IDT team may include
• psychiatrist
• clinical psychologist
• psychiatric clinical nurse
specialist
• psychiatric nurse
• mental health technician
• psychiatric social worker
• occupational therapist
• recreational therapist
• art therapist
• music therapist
• Psycho dramatist
• Dietitian.
• chaplain.
Roles of the Interdisciplinary team
members
 Role of nurse in milieu
•therapy
Milieu therapy can take place in a variety of inpatient
and outpatient settings.
• In the hospital, nurses are generally the only members of the
IDT team who spend time with the clients on a 24-hour basis
• Assume responsibility for management of the therapeutic milieu.
In all settings, the nursing process is used for the delivery of
nursing care.
• Ongoing assessment, diagnosis, outcome identification, planning,
implementation, and evaluation of the environment are
necessary for the successful management of a therapeutic
milieu.
• In the therapeutic milieu, nurses are responsible for ensuring that
clients’ physiological needs are met.
• Nurses are involved in all day-to-day activities that pertain to client
care.
• Suggestions and opinions of nursing staff are given
serious consideration in the planning of care for
individual clients.
• Information from the initial nursing assessment is used to
create
the IDT plan.
• Nurses have input into therapy goals and participate in the
regular updates and modification of treatment plans.
• In some treatment facilities, a separate nursing care plan is
required in addition to the IDT plan.
• When this is the case, the nursing care plan must reflect
diagnoses that are specific to nursing and include problems and
interventions from the IDT plan that have been assigned
specifically to the discipline of nursing.
• Clients must be encouraged to perform as independently as possible
in
fulfilling activities of daily living.
• ongoing assessments to provide assistance for those who require .
• Assessing physical status is an important nursing responsibility
that must not be overlooked in a psychiatric setting that
emphasizes holistic care.
• Reality orientation for clients who have disorganized thinking or
who are disoriented or confused is important in the therapeutic
milieu.
• Clocks with large hands and numbers, calendars that give the day
and date in large print, and orientation boards that discuss daily
activities and news happenings can help keep clients oriented to
reality.
• Nurses should ensure that clients have written schedules of
activities to which they are assigned and that they arrive at those
activities on schedule.
• Some clients may require an identification sign on their door to
remind them which room is theirs.
• On short-term units, nurses who are dealing with psychotic clients
usually rely on a basic activity or topic that helps keep people
• management of medication administration on inpatient
psychiatric units.
• In some treatment programs, clients are expected to accept the
responsibility and request their medication at the appropriate
time.
• encourage clients to be self-reliant.
• Nurses must work with the clients to determine methods that result
in achievement and provide positive feedback for successes.
• nursing in the therapeutic milieu is the one-to-one relationship
that grows out of a developing trust between client and nurse.
• Many clients with psychiatric disorders have never achieved the
ability
to trust.
• If this can be accomplished in a relationship with the nurse, the
trust may be generalized to other relationships in the client’s life.
• Within an atmosphere of trust, the client is encouraged to
express feelings and emotions and to discuss unresolved issues
that are creating problems in his or her life.
• setting limits on unacceptable behavior in the therapeutic milieu.
• This requires stating to the client in understandable terminology
what behaviors are not acceptable and what the consequences
will be should the limits be violated.
• These limits must be established, written, and carried out by
all staff.
• The role of client teacher is important in the psychiatric area, as it
is in all areas of nursing.
• Nurses must be able to assess learning readiness in
individual clients.
• Some topics must be individualized for specific clients,
whereas others may be taught in group situations.
Patient education
• Ways to improve self esteem
points
• Ways to manage anger appropriately
• Stress management
• Identify the increasing anxiety and reduce its progression.
• normal stages of grieving and behaviors associated
with grieving.
• Assertiveness techniques
• Relaxation techniques
• Medications
• Effects of substance on the body
• Problem solving skills
• Thought stopping and thought switching skills
• Sex education
• Good nutrition
• Parental guidelines
• Milieu therapy interventions are recognized as one
of the basic-level functions of psychiatric-mental
health nurses as addressed [in the Psychiatric-
Mental Health Nursing: Scope and Standards of
Practice, (ANA, 2007)].
 Summar
• tick y
s
Discussio
n
 Conclusio
• Milieu therapy has been n
described as an excellent framework for
operationalizing [Hildegard] Peplau’s interpretation and extension
of Harry Stack Sullivan’s Interpersonal Theory for use in nursing
practice.
• therapeutic milieu concept and to reclaim nursing’s
traditional milieu intervention functions.
• Nurses need to identify the number of registered nurses necessary
to carry out structured and unstructured milieu functions
consistent with their Standards of Practice.
References
• Vyas A. Ahuja N . post graduate text book of psychiatry .15th ed
.jaypee brothers , New Delhi ; Pp-428-91
• Saddock . Kaplan . Synopsis of psychiatry . 11th Ed Jaypee brothers .
New York .Pp 647
• Townsend MC. Essentials of psychiatric nursing . 7th ed . Moseby ,
New York .Pp- 165-74