PRAGYAN COLLEGE OF NURSING

BHOPAL, M.P.

SUBJECT – MENTAL HEALTH NURSING

TOPIC – MILIEU THERAPY

SUBMITTED TO: SUBMITTED BY:

MR. PRINCE MATHEW MR. ARVIND PATEL
ASSOCIATE PROFESSOR M.Sc. NURSING I YEAR
PRAGYAN COLLEGE OF NURSING
BHOPAL

DATE OF SUBMISSION – 6/09/2019

 Milieu Therapy – The Therapeutic Community

Introduction:
The word milieu is a French word meaning middle. The English translation of the word is
surrounding, or environment as used in psychiatric mental health nursing, it refers to the people
and all other social and physical factors in the environment with which the client interacts.

A Therapeutic Milieu is a 24 hour environment designed to provide a secure retreat for

individuals whose capacities for coping with reality have deteriorated. The therapeutic milieu
gives them opportunities to acquire adaptive coping skills. By offering secure, comfortable
physical facilities for sleeping, dining, bathing, and engaging in recreational, occupational,
social, psychiatric and medical therapies, the therapeutic milieu does many advantages.

Definition:
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. Nursing’s focus of establishing interpersonal relationships
with client’s fit well within this concept of therapy. Patients were encouraged to be active
participants in this therapy, and individual autonomy was emphasized.

Although strategies for milieu therapy are still used, they have been modified to conform to the
short-term approach to care or to outpatient treatment programs. Some programs (e.g. those for
children and adolescents, clients with substance addictions, and geriatric clients) have
successfully adapted the concepts of milieu treatment to their speciality needs.

Basic Assumptions:
Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based:

 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 health aspects of the individuals 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.
 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.
 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.
 Each client owns his or her behaviour: Each individual within the therapeutic community is
expected to take responsibility for his or her own behaviour.
 Peer pressure is a useful and 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.
 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.
 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.

Functions of Milieu Therapy:

Shelters clients physically from what they perceive as painful, terrifying stressors.
Protects client physically from discharges of their own and others maladaptive behaviours.
Support the physiological existence of clients.
Provides pleasant, attractive, sensory stimulation to clients.
Educates clients and their families about adaptive, effective coping.

Characteristics of a Therapeutic Milieu/ Elements of Milieu Therapy:

 Individual treatment program:
A therapeutic milieu is tailored to the client’s individual needs without infringing on the needs
and rights of other clients. A definite structure, schedule, overall guidelines and social controls
are set forth to provide organization and predictability.
 Self governance:
To avoid the cultivation of dependence and regression, clients are encouraged to participate in
decision-making regarding milieu issues. Structured community meetings client-team meetings
and client –team committee meetings held at regular scheduled intervals to help the client to
find opportunities to develop decision-making skills by involving in milieu decisions.
 Progressive levels of responsibility:
In a therapeutic milieu, clients are expected to assume a responsible role in the maintenance of
the environment. The degree of responsibility expected of clients is depending upon their
 capabilities. This approach is a form of behaviour modifications in that it rewards and
reinforces adaptive behaviour. The level of responsibility assigned to client depends upon the
speed of improvement they show in their illness process.
 A variety of meaningful activities:
To minimize social withdrawal and regression, therapeutic milieu must provide each client with
an individual activity schedule. Such activities may include structured exercise classes, jogging,
training in interpersonal skills (e.g. assertive training, listening, parenting) grooming classes,
arts, crafts, relaxation training and stress management classes, dance classes, and work and
occupational therapies.
 Links with client family:
Therapeutic milieu provides opportunities for clients to re enter the main stream of family life
at their own pace. Links with the family is accomplished in several ways. Family visits are
incorporated into the overall therapeutic milieu program by including family members in
selected milieu activities. Family counselling are provided to help clients and their families
work through the conflicts and problems that inevitably arise during visits.
Including family members in selected milieu activities, such as mental health classes,
interpersonal skill classes, and medication classes, enables mental health team members to
observe family dynamics and to model adaptive interpersonal behaviours to both clients and
their families.
 Links with the community:
Activities occurring outside the structured milieu, such as shopping trips, picnics, camping
trips, attending movies and plays, serve to link clients to community life. Participating in such
activities with mental health team members help clients develop the social skills and confidence
needed to re enter the community.
 Effective working relationships among mental health team members:
Interpersonal conflict occasionally occurs in any group of people. When mental health team
members can engage in effective conflicts resolution, they are more likely to trust each other
and to act and interact as a mental health team and not as a lone therapist. Mental health team
members who can resolve interpersonal conflicts are effective role models for clients.
 Humanistic mental health team members:
Mental health team members need to possess the following attributes:
 Optimistic attitudes towards people in general
 The ability to inspire hopefulness in clients and in others
 Creativity in working towards more effective ways of involving clients in the environment
 Lack of fear or prejudice when confronted with persons exhibiting unconventional or aberrant
behaviour
 Willingness to maintain frequent personal contacts with clients on a daily basis
 The ability to set limits on their own behaviour and the behaviour of others in a non-punitive
manner
 Willingness to share control and decision making with team members and clients
 The belief that controls and limits should be provided by the people to the greatest extent
possible, rather than by locked doors, physical restraints or psycho chemotherapeutic agents.

Components of Milieu Therapy:

Comfortable, secure physical facilities, the mental team and the mental health team and the
therapeutic milieu program are the three essential components of a therapeutic milieu. The total
milieu acting as the primary therapeutic agent is referred to as milieu therapy.

Milieu Therapy Approach:

Milieu therapy is a group therapy approach that uses a total living experience-recreational
occupational, psychosocial, psychiatric, nursing, and medical therapies, plus mental health
team-client relationships-to accomplish therapeutic objectives. Some of those objectives are,

 Correct or redefine their perception of stressors.

 Correct maladaptive coping behavioural patterns.
 Develop adaptive coping behaviour patterns.
 Acquire interpersonal and stress management skills in order to conduct themselves more
effectively in the environment and or correct their coping abilities.

The Program of Therapeutic Community:

Care for client in the therapeutic community is directed by an interdisciplinary treatment 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. 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 the therapeutic community

The Interdisciplinary Treatment Team in Psychiatry:

S.N TEAM RESPONSIBILITY CREDENTIALS

o MEMBER
1. Psychiatrist Serves as leader of the team. Medical degree with
Responsible for diagnosis and residency in psychiatry and
treatment of mental disorders. license to practice medicine.
Perform psychotherapy,
 prescribes medication and
other somatic therapies.
2. Clinical Conducts individual, group, Doctorate in clinical
psychologist and family therapy. psychology with 2 to 3 year
Administers, interprets, and internship supervised by a
evaluates psychological tests licensed clinical psychologist.
that assist in the diagnostic State license is required to
process. practice.
3. Psychiatric Conducts individual, group, Registered nurse with
clinical nurse and family therapy. Presents minimum of a master’s
specialist educational programs for degree in psychiatric nursing.
nursing staff. Provides Some instructions require
consultation services to nurses certification by national
who require assistance in the credentialing association.
planning and implementation
of care for individual clients.
4. Psychiatric Provides ongoing assessment Registered nurse with
nurse of client condition both hospital diploma, associate
mentally and physically. degree, or baccalaureate
Manages the therapeutic milieu degree. Some psychiatric
on a 24 hour basis. Administers nurses have national
medications. Assist clients with certification.
all therapeutic activities as
required. Focus is on one to
one relationship development.
5. Mental health Functions under the Varies from state to state.
technician supervision of the psychiatric Requirements include high
nurse. Provides assistance to school education, with
clients in the fulfilment of their additional vocational
activities of daily living. education or on the job
Assists activity therapies as training. Some hospitals hire
required in conducting their individuals with
groups. May also participate in baccalaureate degree in
one-to-one relationship psychology in this capacity.
development. Some states require licensure
examination to practice.
6. Psychiatric Conducts individual, group, Minimum of a master’s
social worker and family therapy. Is degree in social work. Some
concerned with client’s social states require additional
needs, such as placement, supervision and subsequent
 financial support, and licensure by examination.
community requirements.
Conduct 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.
7. Occupational Works with clients to help Baccalaureate or masters
therapist develop or redevelop degree in occupational
independence in performance therapy.
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 skills
are used.
8. Recreational Uses recreational activities to Baccalaureate or master’s
therapist promote clients to redirect their degree in recreational therapy
thinking or to rechannel
destructive energy in an
appropriate manner. Clients
use skills that can be used
during leisure time and during
times of stress following
discharge from treatment.
9. Music Encourages clients in self Graduate degree with
therapist expression through music. speciality in music therapy.
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.
 10. Art therapist Uses the client’s creative Graduate degree with
abilities to encourage speciality in art therapy.
expression of emotions and
feeling through artwork. Helps
client to analyze their own
work in an effort to recognize
and resolve underlying
conflict.
11. Psycho Directs client in the creation of Graduate degree in
dramatist a drama that portrays real life psychology, social work,
situations. Individuals select nursing or medicine with
problems they wish to enact, additional training in group
and other clients play the role therapy and speciality
of significant others in the preparation to become a
situations. Some clients are psycho dramatist.
able to act out problems that
they are unable to work
through in a more traditional
manner. All members benefit
through intensive discussion
that follows.
12. Dietician Plans nutritious meals for all Baccalaureate or master’s
clients. Works on consulting degree with speciality in
basis for clients with specific dietetics.
eating disorders, such as
anorexia nervosa, bulimia
nervosa, obesity, and pica.
13. Chaplain Assesses, identifies, and College degree with advanced
attends to the spiritual needs of education in theology,
the clients and their family seminary, or rabbinical
members. Provides spiritual studies.
support and comfort as
requested by client or family.
May provide counselling if
educational background
includes this type of
preparation.

ADVANTAGES OF THERAPEUTIC COMMUNITY:

 Patients develop harmonious relationships with other members of the community.
 Residents will gain self confidence.
 Learns to understand themselves and understand others.
 Develops leadership skills.
 Promotes collective thinking and participates in social activities.
 Participates in formulation of rules and regulations of community by actively involving in
community meetings.
 Residents learn adaptive acceptable behaviour in the therapeutic environment.
 Helps to improve self esteem.
 Residents will become less dependent and passive.
 Enhances interaction among residents.
 Residents and staff members will be involving in decision making process actively
 It creates positive attitude and inculcates conductive approach to live happily among residents, as
it creates homely atmosphere
 Client will be able to learn adaptive, acceptable behaviour
 Residents will be able to control their negative emotions e.g. hostility, anger

DISADVANTAGES OF THERAPEUTIC COMMUNITY:

 As it is a group responsibility, there is a chance nobody will feel a sense of responsibility

 Individual’s needs and concerns may not be met
 Client may find the transition and difficulty to survive within the community
 Role confusion may be felt for both staff and residents

NURSES ROLE IN MILIEU THERAPY:

 Use nursing process to provide comprehensive care.

 Provide direct client care:
o Manages the day-to-day care of individual clients
o Assists the client for re-entry into the community
 Give indirect client care:
o Maintains ongoing communication with other mental health team members.
o Enforces rules, policies and regulations of therapeutic milieu
o A schedule, assigns, manages, and evaluates clinical work
 Administer medication and give medication teaching
 Provide psychosocial care:
o Uses informal group interventions such as community meetings and structured or
unstructured group therapy sessions to assist client with problems in their current life
situations
o Conduct brief on the spot counselling with client and families
o Sets limits to deal with behaviours destructive to the self, others, or the environment
 o Helps the clients use their time productively for leisure and work
o Involves withdrawn clients in the milieu
o Encourages clients who have low self-esteem to value themselves
o Serves as a role model by demonstrating inter personal effectiveness in relating to clients
and other mental health members
o Conducts one to one therapy sessions daily with selective clients
o Conducts group therapy on a daily basis to help clients to gain self awareness about how
they behave in groups
o Uses attitude therapy-active friendliness, passive friendliness, kind firmness, matter-of -
factness and no demand are some of the fundamental attitudes that nurses make use
 Provide mental health teaching:
o Psychotropic medications, methods of coping, inter personal effectiveness (e.g.
assertiveness training, communication, problem-solving skills, parenting skills and so
forth) stress management, relaxation and physical exercise
 Encourage clients to understand each other’s feelings and problems
 Assist clients to understand each other’s feeling and problems
 Conduct community meetings
 Participate freely in milieu activities (i.e. exercise, art, craft classes, social function)

CONCLUSION:

A therapeutic milieu is a safe space, a non punitive atmosphere in which caring is a basic
factor. This milieu includes safe physical surroundings, all the treatment members, and other
clients. Nurses play a crucial role in the management of a therapeutic milieu. They are involved
in the assessment, diagnosis, outcome identification, planning, implementation and evaluation
of all treatment programs. They are responsible for ensuring that clients basis needs are
fulfilled, assessing physical and psychosocial status, administering medication, helping the
client develop trusting relationships, setting limits on unacceptable behaviours, educating
clients, within the limits of their capacity, to become productive members of society.

BIBLIOGRAPHY:

1. Lalitha K. Mental Health and Psychiatric Nursing. 1st edition. Bangalore: V.M.G.Book
House; 2007

2. Townsend C. Mary. Psychiatric mental health nursing.5th edition. New Delhi: J.P.Brothers
Publication; 2007

3. Sreevani R. A Guide to Mental Health and Psychiatric Nursing. 2 ndedition. New Delhi: J.P
Brothers Publication; 2007

4. Neeraja K.P (2008). Essentials of mental health and psychiatric nursing, (1st Ed), New
Delhi, Jaypee Brothers