TIME SPECIFIC CONTENT TEACHING EVALUATION

OBJECTIVE AND
LEARNING
ACTIVITY

Student
teacher will
be able to:

INTRODUCTION TO SELF:

- establish Good Afternoon, I am “RINI SAMUEL” student of M.Sc (N) 1st year in
rapport with M.M College of Nursing; Mullana; Ambala.
the group.

INTRODUCTION TO THE TOPIC:

- introduce Today I will be discussing about the topic “MILIEU THERAPY”.

the topic

Student will be
able to :

INTRODUCTION:

- introduce the The locus of milieu is living, learning and working environment. The
topic. defining characteristics of treatment are the use of the team to provide
treatment and the time the patient spends in the environment. Recent
 adaptations include 24-hour-a-day programs situated in community.

DEFINITION:

- define “A scientific structuring of the environment in the order to effect

Milieu behavioral changes and to improve the psychological health and
therapy functioning of the individual “(Skinner, 1979).

GOALS OF MILIEU THERAPY:

- state the  To minimize the anti-therapeutic environment for the patient in the
goals of ward for example, telling other nurses that he is always sad; let
Milieu him stay in the bed only. (Example of anti-therapeutic
therapy environment).

 To minimize prolongation of hospitalization by helping in early

recovery.

 To minimize maladaptive behavior. Creating an environment where

maladaptive behavior is discouraged.

 To provide a free and favorable climate in which the patient can

talk and gain awareness of his own feeling, impulses and behavior.

PRINCIPLES OF MILIEU THERAPY:

- state the  Therapeutic community is an approach used for the care of

principles of mentally ill patient through group activity.
Milieu
therapy  Democracy is observed in a hospital setting. Democracy helps in
increasing the self respect of a patient.
 The patient is involved in his own therapy which helps in making
decision.

 Decision – making ability improves the self-confidence of patients.

 It provides an environment of free communication. Hospital

authoritativeness is reduced.

 The patient is also directed to focus his attention not only on his
own needs but also on the needs of other patients.

 In the mental hospital or psychiatric ward, patient is away from

society so, they feel isolated. Milieu therapy reduces social isolation
and dehumanization of a large hospital. In the large hospital it is
difficult to maintain one to one contact, patient are considered as
bed no., suffering from types of schizophrenia and not by name.

 It attempts to reduce the feeling in the patient about the supreme

power of doctor. The patient feels that he can approach the doctor.

 Thought the nurse set the limit and various roles to play, still the
patient consider her part of the milieu in which he is living. The
nurse needs to be considered in setting limit.

 Continuous assessment should be made to evaluate the progress

of the patient. Modification should be made in nursing interventions.
 BASIC ASSUMPTIONS:

- explain the Skinner (1979) outlined seven basic assumptions on which a

basic therapeutic community is based :
assumptions
in Milieu 1. The health in each individual is to be realized and encouraged
therapy to grow:
All individual are considered to have strengths as well as limitation.
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 relation ship development skills.
Learning occurs from immediate feedback of personal
perceptions.

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 behavior :

Each individual within the therapeutic community is expected to
take responsibility for his or her own behavior.
 5. Peer pressure is a useful and a powerful tool:
Behavioral group norms are established through peer pressure.
Feed back is direct and frequent, so that behaving in a manner
acceptable to the other members of the community becomes
essential.

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.

7. Restrictions and punishment are to be avoided:

Destructive behaviors can usually be controlled with group
discussion. However, if an individual requires external control,
temporary isolation is preferred over lengthy restriction or other
harsh punishment.

DISTURBING BEHAVIORS TACKLED IN THE MILIEU

THERAPY

- enlist the
DISTURBING BEHAVIOR DEFINITION
disturbing
behaviors
tackled in Destructiveness Physical destructive behavior – it is
Milieu a response to variety of feeling,
therapy such as fear or anger.
Disorganization Distorted or unusual behavior a
psychotic patient may exhibit as
symptomatic of the illness – it may
be triggered by elevated anxiety,
profound depression, or organic
dysfunction.

Deviancy Behaviors often described as acting

out - they are the result of the
patient expression conflict overtly in
the environment. It is often difficult
to determine precisely what acting
out behavior is, as well as what is
justifiable or even tolerable
because much of it may be
influenced by socio-culture factors.

Dysphoria Patient with mood alteration may be

dysphoric, which is evident in
maladaptive responses such as
withdrawal from the environment,
obsessional behaviors,
intrusiveness or hyper religiosity.

Dependence Evidenced by patient who do not

identify and meet their own needs
despite being able to do so - the
avoidant nature of dependency
interferes with therapeutic progress.
 IMPORTANT ASPECT OF MILIEU COMMUNITY:

- describe the GOVERNING SYSTEM

important
aspects in  Communication is open and free.
Milieu
therapy  The goals are:
(a) to improve self esteem
(b) minimize hospital stay and disability and
(c) to minimize anti-therapeutic environment.

 The patient and staff get frequent opportunities to participate in

hospital administration. For example, if tea is served at 7’ o clock
the patient may discuss and make arrangement that is served at
8’ o clock as most of the patient are on sedatives and get up late.

 Emphasis in a therapeutic community is placed on social and

group interaction with in individual patient and staff. Both are
important member of the community.

 A successful therapeutic community requires that both the staff

and the patient become fully aware of their roles, limitations and
responsibilities.

 Though staff member are in a position of final authority, much of

the operation of the administration is in the hands of the patient.

 The hospital unit remains in close contact with outside agencies

so that the patient can be provided with required information, may
 be job opportunities, half way homes.

ADMINISTRATIVE ORGANIZATION

THERAPEUTIC OR ANTITHERAPEUTIC effect of milieu therapy will

depend on the hospital setting. If the hospital organization believes in
the type of approach for mentally ill patients, the effect can be
achieved. Otherwise it is difficult for a unit to achieve these goals in our
country it may be difficult initially but once the hospital get to know the
advantage for the patient such as approach will be practical.

ADVANTAGE FOR PATIENT

 Milieu therapy creates a different type of attitude and behavior in

the patient become the environment is like home.

 Instead of adopting a sick role the patient makes decision in the

ward management and cares for others patient. In word he
becomes less dependent a passive.

 The patient learns to adopt a behavior which is acceptable in the

therapeutic environment like learn to control hostility.

 The patient learns to make a decision which improves his self-

confidence.
 THE INTERDISCIPLINARY TREATMENT TEAM IN
PSYCHIATRY
- describe the
inter- TEAM MEMBER RESPONSIBILITIES
disciplinary
treatment
team Psychiatrist  Serve as the leader of the team.
 Responsible for diagnosis and
treatment of mental disorder.
 Performs psychotherapy, prescribes
medication and other somatic
therapies.

Clinical psychologist  Conduct individual, group and family

therapy.
 Administers, interprets, and
evaluates psychological test that
assist in the diagnostic process.

Psychiatric clinical  Conduct individual group and family

nurse specialist therapy.
 Present educational programs for
nursing staff.
 Provides consultation services to
nurses who require assistance in the
planning and implementation of care
 for individual clients.

Mental health  Function under the supervision of the

technician (also psychiatric nurse.
called psychiatric  Provides assistance to clients in the
aide or assistant or fulfillment of the activities of the daily
psychiatric living.
technician)  Assists activity therapists as required
in conducting their groups.
 May also participate in one to one
relationship development.

Psychiatric social  Conducts individual, group and family

worker therapy.
 Is concerned with client’s social
needs, such as placement, financial
support, and community
requirements.
 Conducts in depth psychosocial
history on which the need
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.
Occupational  Work with client to help develop (or
therapist redevelop) independence in
performance of activities of daily
living.
 Focus is on rehabilitation and
vocational training in which client
learn to be productive thereby
enhancing self-esteem.
 Creative activities and therapeutic
relationship skill are used.

Recreational  Uses recreational activities to

therapist promote client to redirect their
thinking or to rechannel destructive
energy in an appropriate manner.
 Clients learn skills that can be used
during leisure time and during times
of stress following discharge from the
hospital. Eg: - include bowling,
volleyball, exercises, and jogging.
Some programs include activities
such as picnics, swimming and even
group attendance at the state fair
when it is in session.

Psychiatric nurse  Provide ongoing assessment of client

condition, both mentally and
physically.
 Manages the therapeutic milieu on a
24-hour basis.
  Administers medications.
 Assists client with all therapeutic
activities as required.
 Focus is on one – to – one
relationship development.

Music therapist  Encourages clients in self expression

through music .client listen to music,
play instruments, sing, dance, even
compose song that help them get in
touch with feelings and emotions that
they may not be able to experience in
any other way.

Art therapist  Uses the client’s creative abilities to

encourage expression of emotions
and feelings through art work.
 Helps clients to analyze their own
work in an effort to recognize and
resolve underlying conflict.

Psychodramatist  Direct clients in the creation of a

“drama” that portrays real-life
situation .Individuals select problem
they wish to enact, and other client
play the roles of significant others in
the situations. Some clients are able
to "act out” problem that they are
unable to work through in more
 traditional manner. All members
benefit through intensive discussion
that follows.

Dietitian  Plan nutritious meals for all clients.

 Works on consulting basis for clients
with specific eating disorder such as
anorexia nervosa, bulimia nervosa,
obesity and pica.

Chaplain  Assesses identifies and attends to

the spiritual needs of the client and
their family member.
 Provides spiritual support and
comfort as requested by client or
family.
 May provide counseling if
educational background includes this
type of preparation.

FOUR PSYCHOSOCIAL SKILLS USED IN MILIEU

 THERAPY:

Once maladaptive behaviors are limited, the therapeutic milieu can be

used to foster the development of four important psychosocial skills in
- explain the mentally ill patients as follows:
psychosocial
skills used in
 ORIENTATION
Milieu
All patients could achieve a greater level of orientation and
therapy
reality awareness. Orientation is the patient’s knowledge and
understanding of time, place, person and purpose. Awareness
of these elements can be reinforced through all patient
interactions and activities. For example, introducing oneself,
one’s role and the rationale for an interaction helps disoriented
patients attend to their surroundings. Another intervention would
be a “current events” group conducted with patients.

 ASSERTION
The ability to express oneself appropriately can be modeled
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. Some sample interventions include assertiveness
training groups, focus groups for lower functioning patients, or
any facilitated, interactive patient group.

 OCCUPATION
Patients can feel a sense of confidence and accomplishment
through industrious activity. Many therapeutic opportunities are
provided through completion of individual or group hands - on
 activities. Spending time working with patient on something as
simple as a jigsaw puzzle can provide purposeful activity,
physical skill development, and the added benefit of practiced
social interaction.

 RECREATION
The ability to engage in and enjoy constructive leisure activity 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 informal games such as
cards and brief walks outdoors.

FIVE SPECIFIC COMPONENTS OF MILIEU THERAPY:

The most important contribution to the concept of the therapeutic milieu

- describe the came when Gunderson (1978) described five specific components of a
specific therapeutic milieu: containment, support, structure, involvement, and
components validation. These functions are often used to measure the therapeutic
of Milieu effectiveness of the treatment environment.
therapy
 CONTAINMENT
Containment provides for the physical being of patients. It
includes providing food, shelter, medical attention, as well as
taking the steps necessary to prevent the patient from harming
self or others. Thus it includes a continuum of interventions, with
the use of seclusion restraints being the most extreme. It is
intended to reinforce temporarily the internal controls of
patients. Consistent limit setting is essential to meet this goal.
E.g.: use of time outs, room programs, specified observation
periods and seclusion.
 SUPPORT
Support includes the staff’s conscious efforts to help patient feel
better and enhance their self-esteem. It is the unconditional
acceptance of the patients, whatever his or her circumstance.
The function of support is to help patients feel comfortable and
secure and reduce the anxiety. Support can be communicated
through empathy, being available, appropriately providing
encouragement and reassurance, giving helpful directions,
offering food and beverages, and engaging patient in activities
that they are reluctant to do.

 STRUCTURE
Structure refers to all aspects of a milieu that provide a
predictable organization of time, place and person. This
dependability in activity, staff and environment helps the
patients feel safe. Having a predictable timetable of meetings,
group session, and other activities is one feature of structure.
Other nursing example includes the setting of limits and the use
of contracts, token economies, and required meetings.
The patient can then begin to accept responsibility for behavior
and its consequences. Providing structure helps the patient
control maladaptive behaviors.

 INVOLVEMENT
Involvement is a part of the structure that goes beyond
compliance with rules and activities. It refers to processes that
help patients actively attend to their social environment and
interact with it. The purpose is to strengthen a patient’s ego and
modify maladaptive interpersonal patterns. Interpersonal
communication and shared activity provide patients with
opportunities to interact with other in their community. Nursing
 examples of involvement includes use of open doors and open
rounds and facilitating patient-led group activities, and self-
assertive experiences. Programs that emphasize involvement
encourage the use of cooperation, compromise and
confrontation.

 VALIDATION
Validation means that the individual of each patient is
recognized. It is the act of affirming a person’s unique
worldview. Validation can help patients develop a greater
capacity for closeness and a more consolidated identity. The
psychiatric nurse communicates this through individual
attention, empathy, and nonjudgmental acceptance of the
patient’s thoughts, feeling, and perspective. Other nursing
examples of validation include individualized treatment planning,
showing respect for the patient to fail as well as succeed.

THE ROLE OF THE NURSE

Nurses are generally the only member of the IDT team who spends
- explain the time with the clients on 24- Hour basis. They assume responsibility for
role of nurse management of the therapeutic milieu and, accomplish this through use
in Milieu of the nursing process. An ongoing assessment, diagnosis, outcome
therapy identification, planning, implementation, and evaluation of the
environment is necessary for the successful management of a
therapeutic milieu. 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. Nurse have input into the goals of therapy and participate in
the weekly updated and modification of the treatment plan.
In some institution, 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
intervention from the IDT plan that has been assigned specifically to the
discipline of nursing.

In the therapeutic milieu:

 Nurses are responsible for ensuring the clients’ physiological

needs are met. Clients must be encouraged to perform as
independently as possible in fulfilling activities of daily living.
However, the nurse must make ongoing assessment to provide
assistance for those who require it.

 Assessing physical status is an important nursing responsibility

that must not be over looked on the psychiatric unit that
emphasizes holistic care.

 Reality orientation for clients who have disorganized thinking or

who are disorganized or confused is important in the therapeutic
milieu .Clocks with a large hand and number, calendar that
gives a day and date in large print ,and orientation board that
discuss daily activities and news happenings can help keep
client orientation too reality . Nurses ensure that clients have
written schedules of activities to which they are assigned and
that they arrive at those activities on schedule some client may
require an identification sign or their door to remind them which
room is theirs. All of these determinations are made from
ongoing nursing assessments.

 Nurses are responsible for the management of medication

 administration in some psychiatric units, clients are expected to
accept the responsibility and request their medication at the
appropriate time. Although ultimate responsibility lies with the
nurses, he or she must encourage clients to be self reliant.
Nurses must work with the client to determine methods that
result in achievement and provide positive feedback for
successes.

 A major focus of nursing in the therapeutic milieu is the one-to-

one relationship, which grows out of the developing trust
between nurse and clients. Many clients with therapeutic
disorder have never achieved the ability to trust. If this can be
accomplished in the relationship with the nurse, the trust may be
generalized to other relationship in the client’s life. Developing
trust means keeping promises that have been made. It means
total acceptance of the individual as a person, separate from
behavior that is unacceptable.

It means responding to the clients with concrete behavior that

are understandable to him or her (E.g., “if you are frightened, I
will stay with you “,”if your cold, I will bring you a blanket “;”if you
are thirsty, I will bring you a drink of water”). Within an
atmosphere of trust, the client is encouraged to express feelings
and emotions and to discuss unresolved issues that are creating
problem in his or her life.

 The nurse is responsible for setting limits on unacceptable

behavior in the therapeutic milieu. This requires stating to the
clients in the understandable terminology what behavior are not
acceptable and what the consequences will be should the limit
be violated. These limits must be established, written and
carried out by all staff on all shifts. Consistency in carrying out
 the consequences of violation of the established limit is
essential if the learning is to be reinforced.

 The role 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 the individual clients. Do they want to
learn? What is their level of anxiety? What is their level of ability
to understand the information being presented? Topic for client
education in psychiatry include information about medical
diagnoses, side effect of medications, the importance of
continuing and stress management, among others. Some topic
must be individualized for specific clients, whereas others may
be taught in the group situation.